INDIANA DENTISTRY

CONTINUING
EDUCATION
ACCESS TO
CARE
ETHICS
HEALTH CARE REFORM
THIRD-PARTY
INSURANCE ISSUES
RELEVANCE
OF ORGANIZED
DENTISTRY
CHANGING PRACTICE
MODELS
RISING COST OF
DENTAL EDUCATION
THE BUSINESS SIDE
OF DENTISTRY
THE UNRETIRED
DENTIST
10 TRENDS
SHIFTING THE FOUNDATIONS OF INDIANA DENTISTRY
FALL 2012
VOL. 91, NO. 3
INDENTAL.ORG
JOURNAL INDIANA DENTAL ASSOCIATION

1 WWW.INDENTAL.ORG
FALL 2012 VOL. 91, NO. 3
CONTENTS
MAKING SURE OUR PATIENTS ARE COVERED
John R. Roberts, DDS, IDA President-------------------------------------3
REPAIRING DENTISTRYS TATTERED SAFETY NET
Douglas M. Bush, IDA Executive Director -------------------------------4
SPECIAL SECTION:
10 TRENDS SHIFTING THE
FOUNDATIONS OF INDIANA DENTISTRY
HEALTHCARE REFORM
Seema Verma, MPH, and Kaitlyn Shaw ---------------------------------6
THE RISE OF LARGE GROUP PRACTICES
Charles L. Steffel, DDS, MSD-----------------------------------------------8
THE RISING COSTOF DENTAL EDUCATION
John Williams, DMD, MBA
Dean, Indiana University School of Dentistry -------------------------11
WHO WILL WIN THE BATTLE TO
DEFEATBARRIERS TOCARE?
David R. Holwager, DDS----------------------------------------------------15
DENTAL ETHICS: AN OBITUARY
Richard E. Jones, DDS, MSD ----------------------------------------------18
INSURANCE: THREES A CROWD
Terry G. Schechner, DDS---------------------------------------------------22
CONTINUING EDUCATION
Karen E. Ellis, DDS, and Jeffrey A. Stolarz, DDS---------------------24
ANEW COURSE FOR IDA LEADERSHIP
Steven P. Ellinwood, DDS--------------------------------------------------26
THE BUSINESS SIDE OF DENTISTRY
Thomas R. Blake, DDS -----------------------------------------------------28
THE UNRETIRED DENTIST
Michael D. Rader, DDS------------------------------------------------------31
$
$
THE RACE FOR RELEVANCE
Mary M. Byers, CAE ---------------------------------------------------------32
Classied Advertising ------------------------------------------------------36
In Memoriam------------------------------------------------------------------38
New Members----------------------------------------------------------------38
Index to Advertisers --------------------------------------------------------39
FUNNY THING: SOCIAL SKILLS IN DENTISTRY
Randy J. Carroll, DDS-------------------------------------------------------40
SOMETHING ELSE IS ABOUT TOCHANGE
Jack Drone, DDS, Editor, JIDA--------------------------------------------44
EDITORIAL BOARD
Dr. Jack Drone, Editor
Dr. Steven P. Ellinwood, Assistant Editor
Dr. Michael D. Rader
Dr. William B. Risk, Peer Review Editor
Mr. Will Sears, Managing Editor, IDA Director of Communications
Ms. Kari Alting, Advertising Manager
COUNCIL ON COMMUNICATIONS
OFFICERS OF THE INDIANA DENTAL ASSOCIATION
Dr. John R. Roberts, President
Dr. Desiree S. Dimond, President-Elect
Dr. Steven J. Holm, Vice President
Dr. Daniel W. Fridh, Treasurer
Dr. Jack Drone, Editor
Dr. Jeffrey A. Platt, Speaker, House of Delegates
Dr. Jill M. Burns, Vice Speaker, House of Delegates
Dr. Terry G. Schechner, Immediate Past President
Mr. Douglas M. Bush, Executive Director, Secretary
SUBMISSIONS REVIEW BOARD
Dr. Jeffrey A. Dean, Indianapolis, Indiana
Dr. Roger L. Isaacs, Indianapolis, Indiana
Dr. Joseph H. Lovasko, Hammond, Indiana
Dr. Jeffrey A. Platt, Indianapolis, Indiana
Dr. Christopher R. Miller, Indianapolis, Indiana
A publication of the Indiana Dental Association. Custom design by Lane Design.
Mission: Produce and distribute, at a profit, credible, high-quality publications that inform Indiana
dental practitioners about the latest scientific, socioeconomic and political developments affecting
dental practice and oral healthcare.
The Journal is owned and published by the Indiana Dental Association, a constituent of the
American Dental Association, 401 West Michigan Street, Suite 1000, Indianapolis, IN 46202-3233.
Subscription rate of $8 per year to IDA members is included in the annual association dues. Indiana
Alliance Association members may subscribe at the same rate as IDA members. The subscription
rate for retired members is $25 per year; non-members may subscribe at $100 per year. Individual
issues may be purchased for $25 each.
The editor and publisher are not responsible for the views, opinions, theories, and criticisms
expressed in these pages, except when otherwise decided by resolution of the Indiana Dental
Association. The Journal is published four times a year and is mailed quarterly. Periodicals postage
pending at Indianapolis, Indiana, and additional mailing offices.
ManuscriptsScientific and research articles, editorials, communications, and news should be
addressed to the Editor, 401 West Michigan Street, Suite 1000, Indianapolis, IN 46202-3233.
AdvertisingAll business matters, including requests for rates and classifieds, should be
addressed to the Managing Editor, P.O. Box 2467, IN 46206-2467. Deadline for all copy is 15 days
prior to the first month of publication, unless otherwise stated by the editor.
Copyright 2012, the Indiana Dental Association.
Dr. Lorraine J. Celis, Chair
Dr. Thomas R. Blake
Dr. Ted Brauer
Dr. Eric S. Browning
Dr. Jack Drone
Dr. Dawn R. Durbin
Dr. P. Bruce Easter
Dr. Steven P. Ellinwood
Dr. Bruce E. Holder
Dr. Chad R. Leighty
Dr. Thomas M. Murray
Dr. Marc S. Smith
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FALL 2012 VOL. 91, NO. 3
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overhead? This raises another question: Why do some patients
hold the dental office accountable for their benefit plan infor-
mation? They have the agreement with their employer, not the
dentist. What started as a nice gesture to help patients with
their coverage has become a heavy, tedious burden of assumed
responsibility for dental offices.
Another factor interfering with the delivery of optimal care is
agreeing to discounted fees for the sake of being busy. Not only
does the insurance promise that youll get more patients, but by
signing the agreement the dentist guarantees that more care
will have to be provided at the discounted rate, in order to
maintain the current income that would be produced without a
discount. In other words, if your profit margin is cut $15 to $20,
and your overhead is somewhere between 60-70%, youd have
to do twice the dentistry to net the same income. I guess the
important thing is to believe busy hands are happy hands,
whether you can pay your bills or not.
What can be done to change the conundrum in which we
find ourselves? Dentistry cant outspend the insurance indus-
trys marketing program, nor should it engage in propaganda.
The advantage that dentistry does enjoy is one-on-one contact
and building an earned trust with the patient. We as individual
dentists need to take the time to educate our patients about the
value of needed treatment as it pertains to their personal needs.
Treatment dictated and pre-scripted by a benefit plan that is
focused on profitability for the third-party administrator is not
optimal care by any measure.
In addition to educating our patients, we must first be true to
the dental profession and not fall into the habit of only discussing
covered procedures for our insured patients. The comprehensive
treatment plan should be guided only by what is needed, not
what a particular plan allows. Ultimately it is still the patients
decision as to what care they receive, but it is our duty to inform
them, educate them, and preserve patient choice in health care.
Reference
1. Murphy, Mark, DDS, FAGD. Insurance-odontitis: Our Greatest Handicap.
Dentaltown. July 2012.
MAKING SURE OUR
PATIENTS ARE COVERED
And Im not just talking about insurance
John R. Roberts, DDS
IDA President
riginally intended to be an improvement to access to
care, insurance coverage can ironically become a handicap to
optimal care. You might ask, How in the world could financial
benefits become an impediment? There are actually several
reasons I have observed over the last three decades in my prac-
tice, many of them shared by our colleagues.
One type of coverage that does not interfere with the doctor-
patient relationship and is truly a help to patients seeking care is
direct reimbursement from employers, without restrictions as to
what services or procedures are covered. The patient is informed
of their treatment choices and receives reimbursement to pay for
any treatment rendered within a set limit of total costs for a
period of time.
The other limitations that adversely affect providing care
include maximum benefits that have not changed in 30 to 40
years, despite all other costs increasing exponentially. Four
decades ago, $1,000 to $1,500 could allowconsiderable care to
be rendered. Today, that means choosing between one molar
endodontic treatment or one crown, and probably exhausting
all of the yearly coverage. If dental benefits kept up with infla-
tion, $7,000 of allowable yearly care would be the norm for a
typical employer provided plan.
1
I havent heard a good expla-
nation of how dental insurance premiums have more than
kept up with inflation (as have insurance company profits), but
the coverage limit is still around $1,000 each year. More irony:
Some dental insurance companies are enjoying the status of
not-for-profit, while paying their CEOs millions of dollars.
An associated problem has evolved over time as patients want
to stay within the yearly maximum benefit, despite what they
might truly need in a given year. I believe this is why six-month
recall is typicalits what benefits will allow. For non-insured
patients, the recall appointment is set according to the individual
needs of the patient, perhaps three months for periodontal care,
or once a year for a long-time patient of record who rarely, if ever,
needs any treatment.
Wouldnt it be great if not missing the exact six-month recall
by one day didnt cause the insurance company to rule the pro-
cedure to be non-covered? When this happens, do you ask the
patient to pay 100%, or do you make it a freebie and add to your
O
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FALL 2012 VOL. 91, NO. 3
Twelve hundred children a year in Florida get their dental
care under general anesthesia in the hospital, said Dr.
Catalanotto. The hospital expense could have been avoided for
pennies on a dollar had preventive care been provided in a
private practitioners office. At Medicaid rates, the cost would
be $50-60 a visit.
Corporate dental chains, backed by profit-driven private
equity firms, also found themselves in Frontlines line of fire.
Frontline described them as a new system of care, flourishing
in states that have raised Medicaid rates in hopes of getting
more care to kids.
Reporter Miles OBrien asked, Are corporate dental chains
filling the gap, or taking advantage of people in pain? He inter-
viewed corporate executives who defended their model, and
former corporate practice employees who alleged treatment
plans were driven by production quotas and bonus incentives.
It became more about numbers; more about meeting daily
goals, said one former officer manger. The computer system
tracked production in minute detail.
Dentistry was portrayed in an even less favorable light when
Sen. Bernie Sanders (IVermont) issued his February 29, 2012,
report, Dental Crisis in AmericaThe Need to Expand Access.
A Senate hearing held the following day highlighted disparities
in access to dental care and proposed the dental therapist mid-
level provider model as a strategy for getting dental care to the
citizens who need it the most. The report also emphasized dol-
lars wasted on hospital ER visits for dental-related problems.
Because no real dental safety net exists in the United States,
many people turn to the emergency room for care, the report
stated. It cited a PewCenter study that estimated that, nation-
wide, in 2009 there were 830,000 ER visits for preventable
dental conditions. It included specific data from two states:
Iowa, where the average cost to Medicaid for dental related
ER visits was $500; and Florida where the dental ER visits
averaged $765.
The report made only cursory reference to the role of govern-
ment in funding preventive care safety net programs. According
to a 2011 study published in the Journal of the American Medical
Association, when Medicaid payment to dentists increased,
children were more like to see a provider. It quickly added,
However, while increases in reimbursement rates lead to some
increases in access, increasing payment levels alone will not
solve the access problem.
The American Dental Association asserted its own solutions
to the access to care problem in an August 2011 position paper,
Breaking Down Barriers to Oral Health for All Americans:
Repairing the Tattered Safety Net.
The ADAs position agrees with some positions taken in Sen.
Sanders report, but is in sharp contrast to others. It disputes the
claim that there is a shortage of dentists or that mid-level
providers are a solution.
REPAIRING
DENTISTRYS
TATTERED
SAFETY NET
Douglas M. Bush
IDA Executive Director
rinity, a brown-eyed five-year-old clad in a hospital gown,
looked into the camera as her grandmother lamented, No den-
tists want to see children on Medicaidher teeth are infected.
Shes had a lot of pain with them.
Thirty-one-year-old Vanessa traveled eight hours to a chari-
table event in Virginia to have all of her teeth extracted. Ive
been to the ER three times within the last six months. I cant
take the pain. Its too excruciating.
Thus began Frontlines special report entitled, Dollars and
Dentists: The Dental Care Crisis in America. As I sat to watch
the two-part report broadcast on PBS television outlets on June 26,
I braced myself for the anticipated assault on dentistry. Surely
heartless dentists would be blamed for the shortcomings of
our dental delivery system. While there was some of that, I was
pleased to see a thoughtful, fairly balanced documentary.
Hit hard were the states Medicaid systemsFlorida in partic-
ular. The program reported that only ten percent of dentists par-
ticipate in Florida Medicaid, and only 25 percent of Medicaid-
eligible children see a dentist in any given year. Dr. Cesar Sebates,
President of the Florida Dental Association, explained, I looked
into becoming a Medicaid provider because I do believe in giving
back. I noticed that the reimbursement schedule was abysmal
it was maybe 20 percent of what we would normally charge. I
thought to myself, this doesnt make any sense. This is not the
dentists fault.
Dr. Frank Catalanotto, Chair of the Department of Community
Dentistry at the University of Florida College of Dentistry,
explained the absurdity of the States underfunded Medicaid
program. Trinity, the five-year-old girl profiled in the Frontline
investigation, required hospital-based dental surgery that cost
the Florida Medicaid program $18,000.
T
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The ADA believes that the available population of dentists is
not a primary issue, and that precious resources should not be
squandered on unnecessary efforts to augment the workforce
with midlevel providersThe problem is not how many den-
tists there are; but rather where they are, and whether they are
able to serve disadvantage patients, either in private practices
or in connection with clinics, health centers or other facilities.
The ADA concluded with seven fundamental principles
that it feels are crucial to successfully addressing the access to
care problem:
Prevention is essentialThe nation will never drill, fill
and extract its way to victory over untreated dental disease.
But simple low-cost measureswill pay for themselves many
times over.
Everyone deserves a dentistThe existing team system of
delivering oral health in America works well for patients in all
economic brackets. It does not need to be reinvented. Rather,
it needs to be extended to more people.
Availability of care alone will not maximize utilization
In too many cases, people are unable or unwilling to take
advantage of free or discounted care missed appointments
represent erosion of available treatment time that the system
cannot afford to waste.
Coordination is criticalToo many government and gov-
ernment-administered programs suffer from a failure to
manage and exchange information about best practices for
safety net operation.
Treating the existing disease without educating the patient
is a wasted opportunity, making it likely that the disease will
recurAnyone who enters the dental operatory for restorative
care should leave the operatory with an understanding of how
to stay healthy and prevent future disease.
Public-private collaboration worksPrivate practice den-
tists will continue to deliver the hands on care to most of the
population, regardless of the payment mechanism. Make it
easier for the dentists to deliver care and the safety net will
address the oral health needs of more patients.
Silence is the enemyLets take the silent out of the
silent epidemic.
We are taking steps at the Indiana Dental Association to
address these issues head-on. Both in advocacy efforts and
through our various charitable care programs, there are real ways
we can help effect positive change for those who need it most.
In June 2012, IDA President John Roberts appointed a
Charitable Care Workforce to investigate how the Indiana
Dental Association can adopt a strategic approach to charitable
dental care in the state. Watch for updates at www.indental.org.
Editors Note: To view Frontlines story, Sen. Sanders report,
or the ADAs access to care position paper, visit
www.INDental.org/JIDA
Anyone who enters the
dental operatory for
restorative care should
leave the operatory with
an understanding of
how to stay healthy and
prevent future disease.
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FALL 2012 VOL. 91, NO. 3
dental benefits. The selection is further complicated by the fact
that the definition and age cut-off for pediatric dental services
remain unclear. Indiana has not yet selected an EHB benchmark
package or an associated dental benchmark package. Once the
selections are made, they will define the benefit package that
will be considered the EHB benchmark in Indiana.
While the PPACA does not require products in the individual
and small group markets to cover adult dental services, presum-
ably these services will be available to consumers on riders as
they are today. Individuals earning between 100% and 400% of
the Federal Poverty Line (FPL) are eligible for tax credits to pur-
chase coverage in an Exchange; however, these tax credits are
indexed to plans covering the EHB and can only be applied to
coverage considered to be EHB. Thus, the tax credits cannot be
applied to adult dental coverage, and the cost of this coverage
must be borne by the consumer. This is likely to result in many
adults with subsidized health coverage who lack dental coverage.
Stand-Alone Dental Plans on the Exchange
The PPACA-created Exchanges also have a potential impact
on dental coverage. Exchanges are a place that individuals can
shop, purchase, and compare cost and quality of health plans.
Individuals eligible for a tax credit must purchase their plan
through an Exchange. The PPACA requires that an operational
Exchange exist in each state by October 2013. This Exchange
may be a state-based, federal-partnership, or federally operat-
ed Exchange. Regardless of who operates the Exchange, it must
offer stand-alone dental plans. Outside of comprehensive
health coverage, stand-alone dental is the only coverage that is
explicitly authorized and required for all Exchanges. Stand-
alone dental plans on the Exchange will be subject to all appli-
cable qualified health plan (QHP) certification requirements
(requirements for plans that offer on the Exchange) and will be
required to obtain this certification prior to offering their plan
on the Exchange.
Exchanges have several options in how to offer dental bene-
fits to consumers. In addition to the stand-alone dental plans,
pediatric dental benefits could be bundled with health benefits.
The QHP plans could either provide the benefit themselves or
partner with a dental plan. The bundling option will allow for
a single price, which may reduce confusion for consumers.
Another option would be to have stand-alone pediatric plans
and/or adult plans. In this case both pediatric and adult dental
SHIFTING THE FOUNDATIONS OF INDIANA DENTISTRY
HOW NEW FEDERAL LAW AFFECTS
YOUR PATIENTS AND PRACTICE
HEALTHCARE
REFORM
Seema Verma, MPH
Kaitlyn Shaw
The Patient Protection and Affordable Care Act
(PPACA) of 2010 and the recent Supreme Court
ruling have a key impact on the coverage of dental
services. New minimum standards for benefit
packages, the potential Medicaid expansion,
and dental coverage through an Exchange have the potential to
impact access to dental care. Low-income individuals are partic-
ularly vulnerable to a lack of dental coverage, and it is unclear
what the impact of the lawwill be on traditional employer
coverage of dental services and the commercial market.
The Essential Health Benets
Starting in 2014, the PPACA requires every plan sold in the
individual and small group markets to provide a core group of
services called the essential health benefits (EHB). In each state,
the EHB will be indexed to an EHB benchmark plan. As such,
the EHB in each state will be based on the covered benefits
offered through the States largest existing commercial products.
States can choose their EHB benchmark; however, they must
ensure that the benchmark covers all PPACA-required EHB.
The PPACA lists pediatric dental services as EHB, and all states
will be required to include them in their EHB benchmark plan.
None of Indianas EHB benchmark options provide pediatric
dental benefits, as dental services are frequently offered in the
form of a rider. Per federal guidance, benefits offered on a rider
are not considered covered in the EHB benchmark options.
In the case of the pediatric dental benefit, states have been
instructed that if the benchmark plan does not offer pediatric
dental then it must be supplemented with either the pediatric
dental benefits from the Federal Employees Vision and Dental
(FEDVIP) benefit plan or the State Childrens Health Insurance
(SCHIP) dental benefits to create a benchmark for pediatric
7 WWW.INDENTAL.ORG
plans could be offered and priced outside of the general health
benefit. Due to the PPACA EHB requirements, every individual
would be required to select and pay for at least a pediatric den-
tal plan, regardless of whether they wanted the plan or had eli-
gible children. These options are not mutually exclusive, and
an Exchange could require the pediatric benefit to be bundled
with the health benefit (but allow for stand-alone dental plans
for adults).
Offering stand-alone dental plans on the Exchange may spur
more consumers to purchase dental coverage; however, it also
has the potential to create confusion, as only the pediatric portion
of the dental plan will be covered by federal subsidies. Explain-
ing this situation to consumers and developing stand-alone dental
plans that do not overlap with pediatric coverage (possibly
already included in an individuals health plan) will be key con-
siderations as Exchanges are implemented. An Exchange will
have to consider which policy makes it easiest for the consumer
and how the dental insurance market operates today.
Medicaid
The State's Healthy Indiana Plan (HIP) is a non-entitlement
Medicaid waiver program established in 2008 that serves
roughly 40,000 adults. HIP provides health coverage to adults
but does not offer full dental benefits. Although the original
authorizing HIP language required dental services to be offered
as a rider, the Centers for Medicare and Medicaid Services did
not allowthe dental rider to be offered. HIP does offer dental
benefits limited to the Early and Periodic Screening, Diagnosis,
and Treatment (EPSDT) program for individuals aged 19 and
20. Eligible individuals 18 and under receive dental benefits
through SCHIP. In 2011, the Indiana Legislature passed a law
that would make the Healthy Indiana Plan (HIP) the coverage
The Patient Protection
and Affordable Care Act,
and recent Supreme
Court ruling, have a key
impact on the coverage
of dental services.
vehicle for the Medicaid expansion. This occurred before the
Supreme Court decision, and it is currently unclear if Indiana
will commit to a Medicaid expansion, or if CMS will extend
Indiana's waiver. Early estimates indicate an expansion cost of
approximately $2 billion over the next eight years. The future
of the HIP program is also unclear, as it expires in December
2012 and requires federal approval to continue. Additional
uncertainty surrounds whether adult dental services will be
added to the HIP program or to a Medicaid expansion product
in the future.
Conclusion
The PPACA strengthens pediatric dental care and should result
in an improvement and expansion in dental care for children;
however, given the EHB requirements and the uncertainty of the
Medicaid expansion, access to dental care for low- and moderate-
income adults is likely to continue to be a key issue.
About the Authors
Seema Verma, MPH, is the founder and owner of Seema Verma
Consulting, Inc., in Carmel, Indiana. Verma served as the archi-
tect of the Healthy Indiana Plan and is currently helping to
oversee Indiana's implementation of the Patient Protection and
Affordable Care Act.
Kaitlyn Shawgraduated from Randolph College with degrees in
Economics, French, and Mathematics. Shawis currently pursu-
ing a Masters in Public Health from the Indiana University
School of Medicine.
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FALL 2012 VOL. 91, NO. 3
CHANGING PRACTICE MODELS:
THE RISE OF
LARGE GROUP
PRACTICES
Charles L. Steffel, DDS, MSD
Dentistry has long been delivered by a system
that is very much a cottage industry. Thousands
of small offices with one or two doctors provide
oral health care to their patients. The term cot-
tage industry originated hundreds of years ago
when most people lived in rural settings. During the winter
months, there was little work to be done. In order to supple-
ment incomes, individuals or families would work at home
(cottage) with their own equipment producing products such
as clothing, pottery, and furniture. When the Industrial
Revolution came, these small, local sources of goods and
services gave way to large, centralized factories.
Many of you may remember a time when every town and city
had only local stores and restaurants. Nowadays it is hard to find
such businesses that are not national chains. Walmart, Banana
Republic, and Macys are the norm, and McDonalds, Applebees,
and Ruths Chris Steakhouse are virtually everywhere.
In health care, just one generation ago, we filled our pre-
scriptions at the local drug store and got our eyeglasses from
an independent optometrist. These businesses were owned
and operated by neighbors and friends. Today, CVS and
Walgreens are on almost every corner. According to the vision
care trade magazine Vision Monday, Luxottica Retail (operating
under the brands LensCrafters, Pearl Vision, Sears Optical, and
Target Optical) was the top retailer of eyeglasses in 2009, with
sales of over $2.5 billion. Walmart ranked second, and Costco
was fifth!
Can dentistry be far behind? It seems that every day we
see a national dental chain opening a new office just down
the street. Is this the future of our profession?
The Health Policy Resource Center (HPRC) of the American
Dental Association conducts extensive economic and market
research on the dental profession. The most recent surveys,
performed between 2009 and 2011, give us a snapshot of dental
practice today. The 2009 Survey of Dental Practice showed that
over 80% of all dentists in private practice who responded work
in solo or two-doctor offices. Ninety-two percent of private prac-
tice dentists are in offices of four or fewer doctors. Only 8% of
dentists work in practices of five or more doctors. The survey
9 WWW.INDENTAL.ORG
considered dentists to be working in Large Group Practices
if multiple locations were owned or managed by a single busi-
ness unit, even if there were only one or two doctors per
location. Though large group practices are the fastest-growing
segment of the dental profession, these statistics suggest their
presence in the overall market may be smaller than perceived.
For the purposes of analysis and data collection, the HPRC
has classified dental practices into four size groups: Practices
with 1 to 4 dentists are called Solo/Cooperative; 5 to 9 dentists
are called Large Group Practices; 10 to 19 are Larger Groups;
and practices with 20 or more are called Very Large Group
Practices. For this article, any practice with 5 or more dentists
will be referred to as a large group practice (LGP).
Large group practices come in many shapes and sizes. There
are group practices that are wholly owned by dentists in the
group, with or without employed associated dentists. In these
practices, the owner dentists handle most management respon-
sibilities. When these groups reach a critical size, they may
employ non-doctor practice administrators. There may be a sin-
gle, large office location, or multiple locations that encompass a
particular geographic area. These practices are more common
in larger cities and specialty groups. There are many large
group practices of this type throughout Indiana.
Another doctor-owned model utilizes a Dental Service
Organization (DSO). This business structure is sometimes called
the franchise model. There will be numerous offices, typically
with one dentist per location. The dentist owns the individual
practice, but outsources business, marketing, and management
duties to the DSO. While the doctor is not an employee of the
DSO, there are long-term contractual payments to the DSO for
its services. Heartland Dental Care, based out of Effingham,
Illinois, is organized similarly to this type of LGP. Heartland
has over 300 offices in 18 states, with 51 offices in Indiana.
In some large group practices, nearly all dentists are
employees. Although ownership shares may be available to
practice doctors, majority ownership by private-equity firms
is a growing trend. Aspen Dental and Kool Smiles are two of
the largest group dental practices in the country and are owned
by private-equity firms. Aspen Dental has about 350 offices in
22 states, and Kool Smiles, the countrys largest Medicaid dental
provider, has 129 offices in 15 states. Both have a significant
presence in Indiana.
That has raised concerns about their marketing and practice
management. Production-driven practice policies have raised
concerns about overtreatment. On June 26, 2012, PBS aired a
report titled Dollars and Dentists on its Frontline program.
The feature took a long, hard look at claims that the private-
equity owners of these two Large Group Practices were
pressuring their employee dentists to increase profits via
questionable means.
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FALL 2012 VOL. 91, NO. 3
Fontana, CEO of Aspen Dental Management (owned by Leonard
Green & Partners, a Los Angeles private-equity firm), stating
that dentistry is a fragmented, cottage industry ripe for man-
agement services.
Another reason for the growth of corporate owned LGPs may
be the struggling economy and high student debt. It is becom-
ing increasingly difficult for new dental graduates to start a new
practice or purchase an existing one. The cost to equip a new
dental office with state-of-the-art equipment and technology
can exceed a half-million dollars. In the American Dental
Education Associations Survey of Dental School Seniors, 2011
Graduating Class, 88.8% of graduating seniors reported having
educational debt. Of those students with educational debt, the
average debt when entering dental school was $35,670, plus an
additional $180,557 acquired during dental school. Thats over
$200,000 of educational debt before the new doctor sees his or
her first patient! Educational debt is increasing rapidly and is
approaching the average net income of all dentists. New dental
graduates have few options that will give them the income nec-
essary to service this debt. Practice ownership, the dentists
American dental dream, is quickly moving out of reach for the
next generation of practitioners.
There are some positive aspects of large group practice that
are attractive to many new graduates. Employed dentists are free
of the management and administration headaches of practice
ownership. Business and staffing affairs are the responsibility of
the management company. Expensive technology that would be
out of reach for a beginning practice owner is common in many
LGPs. Geographic mobility is especially attractive to employed
dentists whose spouses may have to relocate for their careers.
There are some economic advantages to LGPs. In August,
2009 Rick Workman, DMD, the founder and CEO of Heartland
Dental Care, told the ADA Board of Trustees that they obtain
substantially better pricing for supplies, equipment, and lab
services compared to independent dentists. When asked
about Heartlands fees, Workman stated they are able to
negotiate from a strength position for favorable fees and
pricing with various entities, including insurance companies.
So what does the future of dentistry hold for the new
graduate? Will our cottage industry undergo the same corporate
takeover that overran pharmacy and optometry not so long
ago? Is practice ownership no longer an attainable goal for
current students in our dental schools? Certainly, some change
is inevitable. I have seen so much change, changes that no one
could have foreseen, in the 34 years since I graduated from the
Indiana University School of Dentistry.
Here is what we do know: In the 2010 Survey of Dental
Practice, 86% of private practice dentists were practice owners,
either sole proprietors or partners. Only 10.5% were employed
dentists and 3.5% were independent contractors. Private prac-
tice is still dominated by dentist-owners.
In the case of Kool Smiles, a chain that specializes in treating
children on Medicaid, Frontline reported that several states
have investigated claims of unnecessary care, inflated billing,
and Medicaid fraud. Charges of high-pressure sales tactics and
overtreatment being billed to health care credit cards for
patients of the Aspen Dental chain were investigated. In both
stories, concerns over non-dentist managers influencing treat-
ment planning and clinical decisions were raised.
Senator Charles Grassley (R-IA), ranking member of the
United States Senate Finance Committee, has been investigat-
ing several private-equity owned dental chains. Sen. Grassley
questioned whether dentists at these chains are able to make
clinical decisions for their patients, free from corporate pres-
sure to increase production and profits. While management
companies perform valuable office support services for dental
offices, many believe that they should not be allowed to dictate
patient care decisions. American Dental Association policy
states that dentists should be free to exercise individual clinical
judgment and render appropriate treatment to their patients
without undue influence by any third-party business entity
(Dentists Freedom to Exercise Individual Clinical Judgment
[1997:705]).
So why are these LGPs and chains becoming so popular
now? The ADA Health Policy Resource Center estimates that
from 2009 to 2011, the number of large group practices has
grown 25%. What factors have influenced and enabled this
explosive growth? In August 2010, the New York Post opened
an article with the warning, The private-equity barbarians may
soon be running a dental office near you. The article reported
on private-equity firms bidding for ownership of Aspen Dental
and Kool Smiles, predicting the price for each LGP could
exceed more than $500 million. Why so much? The article said
that most dentists still work outside a management practice,
and that healthcare reform that is cutting into reimbursement
for medical doctors is not affecting dentists. Most important to
private-equity firms, according to the Post, dentistry is one of
healthcares last bastions of fee-based services. The article
pointed out that over 80% of dentists work solo or with only one
other dentist. In other words, dentistry is the last cottage indus-
try remaining in healthcare. Bloomberg.com quoted Robert
Large group practices
come in many types,
including dentists as
owners, shareholders
or employees.
11 WWW.INDENTAL.ORG
In unpublished data collected in 2009, dentists in large
group practices were surveyed about satisfaction with their
current practice situation. Results were grouped by the practice
size. As practice size grew, fewer dentists were happy with their
current situation. In LGPs with 5 to 9 dentists, 73% stated they
preferred their current practice setting. In practices with 10 to
19 dentists, that number fell to 56%. And in the very large group
practices, those with 20 or more dentists, only 42% were satis-
fied with their current practice setting. Another finding of this
survey was that in LGPs, net income per doctor fell as the size
of the practice increased.
One final thought as I look to the future of our profession:
I like to call it the fear factor. We all know that patients fear
going to the dentist. Fear is one of the top reasons people post-
pone or neglect needed dental care. But this fear factor can
sometimes be an advantage to the caring practitioner. As a
referral-based specialist, everyday I hear patients say, I hate
all dentists, except my own. I believe what they really mean is,
I fear all dentists, except my own! I am an endodontist, and
fear is something that must be overcome with every patient.
What I have seen, and grown to appreciate after all these years,
is that patients develop a strong, trusting relationship with their
own individual dentist. A discount coupon or slick advertising
does not easily break the bond of trust between a patient and
his or her dentist. Certainly, we have all lost some patients
due to economic factors, like a change in their insurance plans.
But what amazes me is that most patients stay, in spite of these
economic incentives to leave. I dont believe a corporate chain
builds the same trusting relationship, especially if the patient
sees a different dentist at each visit. People dont fear the phar-
macist or optometrist. Perhaps that is one of the reasons their
cottage industries disappeared.
I see change coming to our profession. That is certain.
Change is inevitable. But I do not see the end of the solo and
small-group practices we know today. Large group practice will
continue to grow and thrive, but I do not believe that large
group practice will be the end of our cottage industry, or the
profession of dentistry.
Editors note: This article represents the opinions solely of the
author, which are not to be accepted as views of the ADA or
IDA unless such statements have been expressly adopted by
that Association.
About the Author
Dr. Charles L. Steffel practices endodontics in Indianapolis,
Indiana, and serves as Seventh District Trustee for the American
Dental Association. Dr. Steffel also served as the 144th President
of the Indiana Dental Association.
A NATIONAL AND INDIANA PERSPECTIVE:
THE RISING
COST OF
DENTAL
EDUCATION
John N. Williams, DMD, MBA
The American public expects competent, well-
educated healthcare professionals to provide
quality care. In turn, it costs money to build and
sustain a quality dental education program to
meet the publics expectations. This investment
is made, however, in order to graduate a competent general
dentistone who possesses the scientific knowledge, technical
skills and the professional ethics to provide excellent oral
healthcare. Of late, higher education has been seen as an
increasingly costly enterprise, resulting in larger student debt
at the time of graduation.
1
The cost of a student receiving a
dental education is no exception to this trend. In order to better
understand the cost of dental education and explore options
to address some moderation of the costs, it is important to
understand the underlying issues, sources and uses of funds.
America has one of the most advanced healthcare systems
in the world. Indiana is a contributor to this system by being in
the business of educating new dentists from as far back as 1879,
a date which marks the opening of the private Indiana College
of Dentistry in downtown Indianapolis. By the mid-1920s, the
dental college had become publica part of Indiana University
and was thus, in part, supported by the state as a public institu-
tion of higher education. Presumably, this was a statement by
the legislature and people of the State of Indiana that the State
desired to have a publicly supported school to assure an appro-
priate number of competent dental graduates to meet the oral
health needs of the people of Indiana. While the IU School of
Dentistry remains part of the Indianas higher education system
today, the level of public financial support has decreased over
time. By comparison, in the early 1960s, tuition was $430 per
year, and the State provided a much larger share of the cost for
a student attending IU. But in 2010-2011, in-state resident tuition
was $26,278 per year, and the state provided a little over 21% of
the annual operating funds.
2
Nationally, the total reported expenditures (excluding
research) to educate a DDS student averaged $91,402/full-time
equivalent (FTE) student/year (2008-2009). Individual dental
$
12
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FALL 2012 VOL. 91, NO. 3
TABLE 5:
Average 4 Year DDS Tuitions 2010-2011
Rank Order by Resident Tuition
RESIDENT $
Nebraska 24,301
Indiana 26,278
Michigan 30,254
Minnesota 31,269
Iowa 31,658
Illinois 33,920
Ohio 36,233
Source: American Dental Education Association Official Guide to Dental Schools 2011
TABLE 6:
Average 4 Year DDS Tuitions 2010-2011
Rank Order by Non-Resident Tuition
NON-RESIDENT $
Michigan 47,364
Iowa 52,020
Minnesota 56,999
Indiana 57,570
Ohio 61,356
Nebraska 64,624
Illinois 72,852
Source: American Dental Education Association Official Guide to Dental Schools 2011
TABLE 4:
Percentage and Dollar Amount of Operating Revenue 2008-09
for IU School of Dentistry
PERCENT DOLLARS
Tuition 32.6 19,065,849
Research 6.9 4,035,410
Patient Care 20.3 11,872,293
Financial Aid 0.4 233,937
State and Local 21.5 12,574,103
Graduate
Medical Education 2.8 1,637,558
Endowment 2.7 1,579,073
Annual Gifts 0.5 292,421
University
Indirect Support 8.9 5,205,094
Other (CE, Auxiliary
Enterprises)* 3.4 1,988,463
TOTALS (%) 100.0 58,484,200
Source: 2009-10 ADASurvey of Dental Education Finances Vol. 5 (September 2011)
*OtherIncludes IUPUI campus assessments
TABLE 1:
Percentage Expenditures 2008-09 US Dental Education
PUBLIC PRIVATE ALL INDIANA
Education 28.8 26.4 28.1 28.2
Research 13.5 7.0 11.4 13.6
Patient Care 26.4 26.2 26.3 28.3
Financial Aid 3.2 2.5 3.0 1.8
Major Capital 2.9 4.1 3.3 3.5
Other* 25.0 33.3 27.9 24.6
TOTALS (%) 99.8 99.5 100.0 100.0
Source: 2009-10 ADA Survey of Dental Education Finances Vol. 5 (September 2011)
*OtherIncludes IUPUI campus assessments. (Note: Columns <100% due to rounding)
TABLE 3:
Percentage Revenue 2008-09 US Dental Education
PUBLIC PRIVATE ALL INDIANA
Tuition 19.1 52.8 30.5 32.6
Research 11.8 7.5 10.4 6.9
Patient Care 21.7 23.3 22.3 20.3
Financial Aid 3.2 0.9 1.1 0.4
State and Local 23.0 1.6 15.8 21.5
Graduate
Medical Education 1.9 0.5 1.5 2.8
Endowment 1.0 2.6 1.4 2.7
Annual Gifts 1.9 2.6 2.2 0.5
University
Indirect Support 14.4 4.5 11.7 8.9
Other (CE, Auxiliary
Enterprises)* 2.0 3.7 2.9 3.4
TOTALS (%) 100.0 100.0 99.8 100.0
Source: 2009-10 ADA Survey of Dental Education Finances Vol. 5 (September 2011)
*OtherIncludes IUPUI campus assessments. (Note: Columns <100% due to rounding)
TABLE 2:
Percentage and Dollar Expenditures 2008-2009
for IU School of Dentistry
PERCENT DOLLARS
Education 28 16,492,544
Research 14 7,953,851
Patient Care 28 16,551,029
Financial Aid 2 1,052,716
Major Capital 4 2,046,947
Other* 25 14,387,113
TOTALS 100 58,484,200
Source: 2009-10 ADA Survey of Dental Education Finances Vol. 5 (September 2011)
*OtherIncludes IUPUI campus assessments
13 WWW.INDENTAL.ORG
Expenditures
Looking at the dental education enterprise across the United
States, two types of schools collectively expended slightly over
$2.71 billion in 2008-2009 to provide education, research and
service in support of the profession. These costs were divided
between state schools ($1.77 billion) and private dental schools
($940 million).
7
Table 1 shows the percentage of dollars
expended for the major areas of operating a dental school.
The major cost is tied to personnel as represented in the educa-
tion and patient care categories, which together make up over
half of the dental school expense. Table 1 further shows the dif-
ference in percentage expenditures between public and private
dental schools. While education and patient care expenses are
similar for both types of schools, private institutions spend less
on research and more of their own monies on other expenses,
since they must self-fund more activities.
Acomparison of the IU School of Dentistry against this
national expenditure profile shows that the major expenses paral-
lel those nationally mainly in education and patient care, although
costs for patient care are slightly higher at IU when compared to
either public or private dental schools. A detailed breakdown by
dollars is shown for IU School of Dentistry in Table 2.
Revenues
Looking at the revenue derived to support the United States
dental education enterprise, the 2009-2010 ADAreport shows
that the two types of schools collectively generated over $2.88
billion in 2008-2009 to provide education, research, and service
in support of the profession. These costs were divided between
state schools ($1.89 billion) and private dental schools ($979 mil-
lion). Table 3 shows the percentage of dollars generated by
source. The major source of revenue for private dental schools
is tuition (52.8%) compared to public dental schools (19.1%) and
private dental schools derive less from research. The University
Indirect Support category for private dental schools is less as
well, since they are expected to pay for more of their own operat-
ing costs at the school level and not at the campus level. Indiana
has a similar arrangement as a private dental school under the
Responsibility Center Management (RCM) financial program in
use at the IUPUI campus. The IU dental school pays for more
local services, but benefits from keeping more tuition and clini-
cal revenue at the dental school.
Again, the comparison of the IU School of Dentistry against
this national revenue profile shows that the major sources of
revenue parallel those nationally mainly from tuition and
patient care. One note is the much larger proportion of revenue
generated from tuition (32.6%) compared to the national aver-
age for public dental schools of (19.2%). Indiana also has a
slightly lower percentage of its revenue coming from state and
school expenditures range, however, from a high of $155,623/
FTE student/year to a low of $46,392/FTE student/year.
3
IU
School of Dentistry spends about $86,000/FTE/year to educate
a dental student, which is slightly below the national average.
4
The major portion of this cost is in support of clinical education.
During the late 1960s through the 1970s, the federal govern-
ment was active in funding health professions education. In a
2005 publication by the federal Health Resources and Services
Administration (HRSA) entitled: Financing Dental Education
Public Policy Interest, Issues and Strategic Considerations, a
brief history of federal financing policy is provided.
5
Federal support for dental education was largely con-
fined to short-term funding some 30-40 years ago and
has been reduced significantly over the past 2 decades,
to the point where less than 1 percent of predoctoral
dental education revenues in 2001 came from Federal
funds. State and local government support for dental
education in public dental schools declined by 25 per-
cent in recent years, from 66 percent of total dental
school revenues in 1991 to 49 percent in 2001, and
continues to fall. State and local government support
for dental education in private dental schools declined
from 10 percent in 1991 to less than 3 percent in 2001.
Declines in public funding for dental education are
widely viewed as a significant factor in the closing and
downsizing of U.S. dental schools over the past two
decades and an impending crisis in dental education.
5
In the decade since this HRSA report was written, state insti-
tutions have continued to replace state support with primarily
tuition and fee dollars to fund dental education. Total direct fed-
eral educational revenue to dental education in 2008-2009
excluding federal grants was only $11 million of $2.9 billion
amounting to only 0.4% of total revenue.
6
State and local funding
represented only 15.8% on average distributed as 23% for public
dental schools and only 1.6% for private ones in 2008-2009 in
sharp contrast to the situation since 1991 as cited above.
6
IU
School of Dentistry is slightly belowthe national figure at 21.5%.
Although IUSD remains
part of Indianas higher
education system, its
level of public nancial
support has decreased
over time.
14
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FALL 2012 VOL. 91, NO. 3
premiums, we probably won't see a roll back in tuition costs,
but we can see a slowing of the annual dental tuition increase,
which in recent years has exceed 8.0% per year.
9
Figure 1 shows
the picture of tuition increases for both resident and non-resi-
dent students from 2001 through 2011. Both groups have
almost doubled over this time period.
In considering what we can do, I offer two possibilities for
consideration of slowing or reducing the costs of dental educa-
tion at IU. There are other ideas, and I welcome your thoughts
about other ways to address the costs of dental education.
Amore exhaustive discussion of cost of dental education can
be found in an article for the Journal of the American Dental
Education Association entitled Dental education economics:
challenges and innovative strategies.
10
Clinical Efciency
Personnel costs of clinical instruction need to be examined
to assure all dental schools are operating clinics efficiently.
This analysis applies to both faculty and staff. At IU, the average
clinical experience, and hence revenue, derived from patient care
based on our reduced fees (approximately half of community
fees), for our D3 and D4 students amounted to about $16,500 per
year in 2009.
11
Once in practice, however, a new graduate needs
to generate two-times that amount per month in order to earn a
basic entry level of compensation. The school could better pre-
pare D4 students by structuring clinical operations and patient
care to expand the volume of care delivered to enhance the stu-
dents educational experience and support a higher revenue
stream.
Curriculum Modications
Undergraduate education has enjoyed success in making
available advanced placement and college level courses at the
high school level. One can argue that based on the competency
philosophy of US dental education, dental students should rou-
tinely be able to place out of various biomedical sciences
courses, based upon satisfactory completion and assessment,
that they have mastered the curriculum. In turn, this would
reduce their educational course load and reduce costs associated
with taking biomedical sciences again once enrolled in dental
school. A further check on student competence is successful
completion of Part 1 and 2 of the examination administered by
the Joint Commission on National Dental Boards, which are
required for dental licensure in all 50 states.
12
local support (21.5%) versus (23%) for other public dental
schools. A detailed breakdown by revenue dollars is shown
for IU school of Dentistry in Table 4.
Tuition
With Indiana having a larger proportion of its operating
revenue coming from tuition, we are seeing the impact of a
greater reliance on tuition to fund the dental school. Tuition is
set by looking at benchmark institutions and approved by the
IU Board of Trustees. One set of benchmarks is the seven Big 10
schools, which nowincludes Nebraska. A review of both in-
state resident and non-resident tuition shows that Indiana is
mid-range when compared against these benchmark programs
for non-resident tuition and at the lower end for in-state dental
school tuition.
8
The strategy has been to keep in-state tuition
relatively low to thwart a student perception of limiting educa-
tional access based on tuition costs. Big 10 in-state resident
tuition ranges from a low of $24,301 to a high of $36,533 (over
a 4 year average). The impact of high tuitions on non-residents
is seen in the Big 10 as well. These four-year average annual
amounts range from a low of $47,362 (Michigan) to a high of
$72,852 (Illinois). Tables 5 and 6 outline the rank order for both
resident and non-resident tuition costs for seven of the Big 10
universities that have dental schools.
8
How to Control the Cost of Education
By understanding the underlying sources and uses of funds for
both public and private dental schools, one can better under-
stand the challenges and changes that might be made to reduce
the tuition cost for students. Like rising US health insurance
\!,
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\1,
\1,
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\t,
Non-Resident
Resident
I!!! I1! I1 II ItI I!t I1! I11 II1 I!I
\1I,111
\II,1t
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\11,I11
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Figure 1:
Tuition Increases for Resident and for Non-Resident Students,
2001-02 through 2010-11
15 WWW.INDENTAL.ORG
Summary
Indiana University School of Dentistry remains committed
to graduate competent general dentists. In the face of the cost
of dental education, we are open to explore alternative educa-
tional and clinical models to enhance the educational
experience for all students, while reducing the cost to provide
that education. As dean, I welcome your thoughts and ideas to
further reduce educational costs.
References
1. USA Today Student loans outstanding will exceed $1 trillion this year.
Oct 27, 2011. At: http://www.usatoday.com/money/perfi/college/story/
2011-10-19/student-loan-debt/50818676/1
Accessed: July 10, 2012.
2. Indiana University Academic Bulletin; School of Dentistry, 1961-62, page 18.
3. American Dental Association: 2009-10 ADA Survey of Dental Education
Finances Vol. 5 Chicago, (September 2011), p. 91.
4. Ibid. p.88.
5. HRSA Financing Dental Education: Public Policy Interests, Issues and
Strategic Considerations 2005
6. American Dental Association: 2009-10 ADA Survey of Dental Education
Finances, Vol. 5 Chicago, (September 2011), p. 6.
7. Ibid. p.7.
8. American Dental Education Association: Official Guide to Dental Schools
2011, for students entering in fall 2012. American Dental Education
Association publication, Washington, DC.
9. American Dental Association, Survey Center, Surveys of Dental Education,
(Group II, Question 15a).
10. Walker MP, Duley SI, Beach MM, Deem L, Pileggi R, Samet N, Segura A,
Williams JN. Dental education economics: challenges and innovative
strategies. Journal of Dental Education December 2008; 72(12); 1440-49.
11. American Dental Association: 2009-10 ADA Survey of Dental Education
Finances, Vol. 5 Chicago, (September 2011), p. 18.
12. Joint Commission on National Dental Examinations.
At: http://www.ada.org/2289.aspx
Accessed: July 20, 2012.
About the Author
Dr. John N. Williams is the Dean of the Indiana University School
of Dentistry.
DEMOLITION DERBY:
WHO WILL WIN
THE BATTLE
TO DEFEAT
BARRIERS
TO CARE?
David R. Holwager, DDS
Access to carehow difficult can this be?
The answer is more complicated than is thought.
Answers could be found in the consideration
of many facets to the primary access problems:
barriers, cultures, demographics, oral health
literacy, physical distances, impairments and economics, to
name a few. The issues of access are also political in nature
and are being used to advance the cause of different groups
to advance their agendas.
The American Dental Association (ADA) convened in 2009
of over fifty different groups who have been identified as stake-
holders in oral health concerns. The groups included
representatives from government agencies, foundations, den-
tal-related industries, Native Americans, professional dental
groups, and consumer groups. The summit was well attended,
with tenuous discussion on the issue.
Finally the group came to the conclusion to put the differ-
ences aside and work towards solutions in areas where there
is agreement. The summit on access then evolved into the U. S.
National Oral Health Alliance. Since the 2009 summit the work
necessary to form the alliance, bylaws, administration, mem-
bership, and economic concerns have been developed and
adopted. Mr. Douglas Bush, Executive Director of the Indiana
Dental Association, was a member of the Alliance formation
group. The ADA joined in the winter of 2011-2012.
The ADA defines mid-level dental provider as any oral
health provider whose training and responsibilities are
between those of ADA-recognized dental team members
(community dental health coordinators, oral preventive assis-
tants, dental assistants, expanded function dental assistants,
and dental hygienists) and those of a licensed dentist.
16
JIDA
FALL 2012 VOL. 91, NO. 3
stainless steel crowns, and recementation of crowns. This
model, like the DHAT, does not require the direct supervision
of a dentist and could practice independently.
Implications
DHATs (both forms) and ADHPs are mid-level models that
perform invasive procedures on patients. The pattern upon
which these models are based is that of the nurse practitioners
used in medicine, but with the significant difference being the
ability to perform invasive procedures.
The American Dental Association (ADA) and the Indiana
Dental Association (IDA) do not support any of the above mod-
els of mid-level providers, but instead offer support to the
doctor who has graduated from a CODA-accredited school of
dentistry and gone through the licensing procedures required
by the State Board of Dentistry.
Currently the ADA is conducting a pilot study for a new type
of dental team member, modeled after the Community Health
Worker (CHW). Called a Community Dental Health Coordinator
(CDHC), the dental team members role is to help solve access to
care issues for the underserved who have difficulty in seeking
dental care. The CDHC helps with the logistics of getting the
patient to and from the care provider, and educates the patient
and community on the importance of good oral health and pre-
vention. The ADAand volunteer members developed the pilot
program such that it would meet CODAstandards, if advanced.
The CDHC is under the supervision of a dentist, who goes into
the community to aid individuals in getting the dental care they
need. The CDHC will help in the raising of the oral health literacy,
along with education in the causes and effects of oral diseases,
especially relating to the decay process.
The functions the CDHC may perform besides education and
logistical support are to be authorized by a dentist, to include
coronal polishing, fluoride treatments, sealant placement, place-
ment of temporized restorations, selective scaling for periodontal
type-one, and gather diagnostic data for the dentist. Note that the
CDHC works under the supervision of the dentist and does not
perform invasive procedures, nor does the team member diag-
nose the oral condition. Neither is the CDHC a mid-level
provider, but a member of the dental team who, like a CHW,
helps the patient navigate their personal access to care issues.
The pilot study involves the development of an educational
model that can either be taught in a classroom setting or via the
Internet through an online course. There is also a required 18-
month internship during which students develop and demon-
strate their clinical skills with the aid of their clinical instructors.
The CDHC study involves individuals with various backgrounds,
including dental hygiene and dental assisting. Some participants
will also come from an expanded functions dental assistant
There are indeed many models that focus on answers to
access. Foundations, individuals in public health, governmental
agencies, and the American Dental Hygiene Association have
all proposed the mid-level provider.
The following is an outline of the major models of workforce
models (mid-level providers) by different groups.
The Dental Health Aid Therapist (DHAT) model consists
of an individual who is a high school graduate with eighteen
months to two years of training and education to perform the
following duties: diagnosis, extractions, pulpectomies, restora-
tions, local anesthesia, prophylaxis, pulp capping, and the
placement and cementation of stainless steel crowns. DHATs
began in New Zeeland but can now be found in Alaska, Canada,
Great Britain, and forty-nine other countries.
Minnesota already has a model of the DHAT, which is taught
at the University of Minnesota and has graduated students who
are now practicing in that state. The educational requirements
have college pre-requisites and consist of a 40-month B.S. pro-
gram followed by a 28 month M.S., as well as licensure by their
state board of dentistry. The duties Minnesotas model can per-
form include the following: anterior primary crowns, diagnosis,
restorations, prophylaxis, extractions, local anesthesia, pulp cap-
ping, stainless steel crowns, prescriptions, space maintainers,
recementation of crowns, and a traumatic restorative technique.
They are not required to be under the supervision of a dentist.
The Advanced Dental Hygiene Practioners (ADHP) is a model
put forth by the American Dental Hygiene Association (ADHA).
The individual would hold a dental hygiene degree, license, and
would complete the educational requirements for certification
as an advanced dental hygiene practioner. The duties an ADHP
could perform are as follows: diagnosis, extraction, periodontal
therapy, pulpectomies, pulp capping, local anesthesia, nitrous
oxide administration, prescriptions for pain relief, orthodontics,
If dentistry doesnt
solve the issues of
access to care,
someone else will.
Opposition without
an alternative solution
is the wrong answer.
17 WWW.INDENTAL.ORG
caseworkers have been a contributing factor to the issues of
access. The basic economic model of any access solution must
work, or it will surely fail.
Conclusions
Access to care issues pose real threats to dentistry as we
know it. If the adoption of any of the DHAT or ADHP workforce
models is deemed acceptable to governmental agencies, how
long does it take for the sub-standard care they provide to be
an acceptable level of care for the entire population? There is a
reason dentists and dental hygienists have a required level of
education and an emphasis on continuing education: It is to
provide the highest possible standard of care for every patient,
not having multiple levels of care.
Dentistry has worked over the years to be a profession where
the level of treatment success is predictable, the patient level of
confidence in care is high, and the level of comfort in treatment
is acceptable. The hallmark of dentistry as well as medicine is
to improve treatment modalities, reduce the discomfort of the
patient, reduce or eliminate the disease process, and educate
the patient in prevention of diseases and good overall health.
A reduction in educational standards for dental health
providers under DHAT or ADHP models will not achieve this.
Advocacy for the oral health of our patients is not just the
responsibility of the leadership of the Association, but the
responsibility of every doctor and dental team member. The
patient must be our first concern, including the underserved.
The IDA and the ADA are working for the profession to retain
dentistrys high standards. You need to not only be a doctor
and educator in your profession, but also an advocate.
About the Author
Dr. David R. Holwager practices general dentistry in Cambridge
City, Indiana, and is the current Chair of the American Dental
Associations Council on Access Prevention and Interprofessional
Relations. He also served as the 148th President of the Indiana
Dental Association.
(EFDA) background or work for a dental clinic, while others will
participate with a high school degree as the highest academic
and/or training credential.
The program has been conducted through four dental
schools thus far: Arizona, Temple, Oklahoma, and UCLA, with
a number of associated clinical sites in rural, urban, and Native
American settings.
The study also involves a evaluation of the education module
and the effectiveness of the CDHC, not only including the differ-
ence it makes in patients access to care, but also the level to
which the provided care increases efficiency of the clinic and/or
dentist. The sustainability of the CDHC must also be proven, for
if the economic model does not work, the cost of the education
will not be worthwhile.
The last cohort of students will finish in September 2012,
with a partial evaluation by this years ADA House of Delegates
and a full report of the program and evaluation of the project for
review and approval of the 2013 ADA House of Delegates. The
ADA, unlike others, will not put forth a model of a new dental
team member unless that model has a positive evaluation.
The Challenge to Have the Right Answer
Dentistrys challenge will be to solve the issues of access or,
quite simply, someone else will do it for us. It has been proven,
as the profession learned in Alaska, that opposition without an
alternative solution to improve the issue of access is the wrong
answer. Governmental bodies will look for a solution, and we
knowthere are already many alternatives for them to con-
siderall claiming to have the answer. The issues of access to
care for the underserved also emerged in medicine, in which
physicians also said no, but offered no other solution to
access; they now have nurse practitioners.
The ADAs solution, unlike the other workforce models, is
not a therapist, but an educator, who has cultural competencies
to explain the importance of good oral health, explain the value
of prevention, and arrange the logistics of care. The well-trained
members of the dental team render care. Under this model,
there is no lowering of the educational requirements or a differ-
ent standard of care for the underserved.
Economic Factors
Access also has an economic side. When reimbursements
rates are fair, there has been an increase in providers and an
increase in utilization of Medicaid services, not to mention a
lowering of complaints from the voters. Underfunding of the
programs, administrative issues with claims, and unresponsive
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The diminishing professionalism was so gradual that the
majority of ethical dentists did not notice. Even the guardian
professional associations did not notice at first. Later they
feared litigation, and did not want to lose members. Some
councils on judicial affairs were disbanded for irrelevancy.
It was too late.
As the possibility for profits grew, fake centers of higher learn-
ing sprang up. The institutes charged high fees, the presentations
were glitzy, and the participants received certificates, master-
ships, marketing packages, national television campaigns, and
the promise of large profit centers. The bastion of professional-
ism had always been the peer standard. Ironically, as organized
dentistry did not notice that tens of thousands were being taught
to perform below the standard of care, those practitioners
increased in mass enough to redefine the peer standard.
Eventually, all areas of oral healthcare focused on profit over
patient. This included some dental manufacturers, some dental
supply companies, some dental laboratories, and even some
auxiliaries. It became increasingly difficult for honest practi-
tioners to compete on an uneven playing field. They became
disgruntled, retired early, and encouraged quality young people
to study other fields.
Arrangements
There is talk of replacing the coveted American dental sys-
tem with the British system. Society is beginning to feel that
since they are getting ripped off with high fees and low service
and the dental associations arent protecting them, then low
fee/lowservice might be okay. Alternative service providers are
evolving and will eventually displace some dentists. The ADA
will become a small group of angry old men that commiserate
about the past. Membership will shrink to study club size
because there will be no compelling reason to belong. Dentists
income will shrink considerably as they compete with lesser-
trained technicians and mid-level providers. A lower standard
of dental care will become acceptable. The respect for dentists
will decline, as they are no longer considered an ethical and
learned profession.
Sound Grim?
Dentistry today is actually not deadyetbut how many
of the aforementioned causes of death are already realities
today? Maybe its not too late for dentistry to address the issue
of profession versus business.
Ethics: The rules of conduct recognized in respect to a partic-
ular class of human actions or a particular group, or dealing
with values relating to human conduct, with respect to the
rightness and wrongness of certain actions and to the goodness
and badness of the motives and ends of such actions.
DENTAL ETHICS:
AN OBITUARY
Richard E Jones, DDS, MSD
It was a tragic day for nearly 150,000 dentists,
their families, and three-quarters of a billion
American dental patients whom they had treated.
It was announced today that the profession of
dentistry is dead.
It was an unexpected shock. Dentistry had long been revered
as one of the most respected of all professions and was consid-
ered by business analysts as a healthy and profitable industry.
Investigators determined a cancer-like disease to be the
cause of death, which was likely undiagnosed for more than 20
years. The century-old profession passed away after a long bat-
tle with hucksterism, false advertisers, uncredentialed training,
fake degrees, and a plethora of dental treatment gadgets.
It took many decades to establish accredited dental schools
and ADA-endorsed specialties, and for practitioners to incorpo-
rate evidence-based materials and techniques into their
everyday practice. American dentistry enjoyed the highest
standard in the world.
It took less than two decades to undermine those efforts and
revert to the roots of barber dentistry. The autopsy report points
the finger at the suit between the American Medical Association
and the Federal Trade Commission, and the subsequent agree-
ment with the American Dental Association, which eventually
redefined the profession as a business and emasculated the
powers of self-regulation. A small group of entrepreneurs dis-
covered that by changing their mission from healthcare to
profit, they could increase their personal income from the top
2% in America to the top 0.5%. This led to false advertising and
violations of clinical standards. Naturally, other dentists gradu-
ally jumped on the profit bandwagon with the feeling that
everyone else was doing it.
The ADA missed the opportunity to proactively defend the
profession from national trends and influences. Professional
self-regulation declined to a state of inactivity. The public was
exposed to billboards advertising painless dentistry, infomer-
cials decrying the use of amalgam (in opposition to the
scientific evidence and the official position of the ADA), unrec-
ognized specialties (cosmetics, sleep apnea, implants),
non-credentialed certifications and fellowships, free exams,
two-for-one product sales, kickback rewards to referrers,
claims of superiority, prioritization of bright-white smiles and
partial treatment over dental health, and on and on. Painless
Parker would be pleased with the dental retail industry of 2012.
19 WWW.INDENTAL.ORG
Society has changed from a loyal, trusting public that viewed
doctors with awe and respect to a suspicious and litigious group
that expects someone else to be responsible for their problems.
Society has become commercial and greedy. Some have come to
accept baloney advertising as credible. Society is subject to
fads, such as cosmetics, and believes them to be more important
than comprehensive care.
Society is susceptible to the direct marketing of products and
techniques. Society has begun to notice the change from a self-
less profession to a production-based retail industry. Societys
change is understandable but it does make it difficult to provide
quality care in a reputable manner.
Government helped to redefine marketing in dentistry when
deciding the profession could not restrain (or self-regulate) trade.
This new interpretation of dentistry as a business may be the
seminal event that will result in the death of the profession as we
know it.
It is unfortunate that the government generally doesnt under-
stand dentistry or appreciate its importance to the health and
productivity of the American citizen. The learned professions are
too complex and sophisticated for legislators and bureaucrats to
micromanage. When government considers that a profession is a
trade and undermines self-regulation, the profession eventually
becomes a trade.
Government and society have begun to notice the changes
in dentistry. They see the emergence of the retail model and
they see the decrease in self-regulation. They never understood
the profession of dentistry; they trusted us to understand and
control. Nowthey realize that they (government and society)
must exert influence and increasing control over the business
of dentistry.
Generational changes in society and in dentistry are having
a significant and noticeable impact on the profession. Loyalty
toward institutions has been replaced with cynicism. Lifestyle
desires and immediacy of gratification are different. Communi-
cation styles are different enough to hinder cross-generational
collegiality and mentorship. In the past, the dental association
provided a formal bond between dentists, and collegiality
was a powerful informal bond that facilitated mentorship
and peer pressure. As dental peers become less similar and
more distant, conformity to our traditionally held professional
values declines.
Mentorship can be a powerful tool for learning clinical
dentistry, practice management, and dental professionalism.
Mentorship has traditionally been a key component of the
profession of dentistry, hardly mentioned and often taken for
granted. Dental mentorship has suffered greatly for a complex
array of reasons. Most notably, perhaps, are growing genera-
tional differences between older and younger practitioners.
Both can learn immensely from one another, but both must first
abandon their preconceived notions about what the other can
offer. Also, new practitioners with huge debt, while feeling
Profession: A vocation founded upon specialized educa-
tional training, the purpose of which is to supply disinterested
counsel and service to others, for a definite compensation,
wholly apart from expectation of excess profit, and is granted
autonomy (self-regulation) by government and society by virtue
of ascribing to a code of ethics.
Business: A profit seeking enterprise.
When a customer buys a car, he may possess the same
knowledge as the salesman. The salesman is interested in
profit. The customer is interested in purchasing a known
commodity for the best price, knowing that protection is
offered by courts and consumer groups. When a patient goes
in for brain surgery (or dentistry), they cannot understand the
process, but believe that they will receive a proper clinical
service for a standard fee knowing that they are protected by
professional standards.
There is a significant difference between a professional
receiving a definite compensation and a business owner whose
mission is excess profit. The dental professional has a mission
to provide a sophisticated healthcare service to a patient with
a specific dental problem, for a reasonable compensation,
and with no interest other than to heal and cause no harm.
The Professional Environment Has
Changed in the Past 20 Years
There are national forces that have caused dental practition-
ers and all parts of the oral health system to change focus. Com-
mercialism is displacing the Hippocratic Oath. Profit motive is
displacing altruism.
In the past, the dental
association provided
a formal bond between
dentists, and collegiality
was a powerful informal
bond that facilitated
mentorship and peer
pressure.
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Dental manufacturers and supply companies used to be
on the oral healthcare team with a mission to advance dental
care for the patient, but some have been seduced by commer-
cialism. Your dental house rep used to provide evidence-based
support for technique; some now pressure you to borrow
money for the purchase of the device du jour in order to make
more profit and keep up with the race for the million-dollar net
practice? The dental trades have a great opportunity to help the
young dentist and establish a career-long partnership that bene-
fits all, including the patient.
Corporate Dentistry
The development of an assembly line model makes sense
to a non-dentist. The treating doctor may not plan treatment;
a specific time may be allotted for a certain class of restoration
that is expected to produce a certain profit; and undue pressure
incentives may be placed upon the dentist worker. Does this
system make sense to a professional healthcare provider, a
learned doctor, or a trusting patient? And does this dental
worker still fit the definition of a professional? Corporate den-
tistry can be a good system for the patient and for the dentist
but the dental profession, the dental association, the ethical
concepts, and the legal and regulatory paradigms are based
on concepts of solo practice. Guidelines have not kept pace
with evolutionary changes and must be restructured.
Debt for young dentists is unprecedented, as are their
incredible setup costsnot to mention unrealistic income
expectations. A $300,000 burden with a million-dollar buy-in
may well discourage the traditional dream of private practice.
Dentistry has been based upon the paradigm of the solo (or
small group) practice. It is a privilege to personalize your prac-
tice to fit your mission, vision, and personal values.
Is the dental corporation owned by a non-dentist or a pri-
vate-equity group? Is the mission profit based? Is the dentist
empowered to make treatment decisions based upon their own
professional values? It should be noted that dental corporations
placing oral health over profit are a valuable part of the profes-
sion of dentistry.
Academia has always been part of the learned professions,
but it has now been tainted by commercialism. How much con-
trol does the business side of the university now exert? Is pres-
sure to demonstrate profit affecting curriculum and teaching
methods? Is tuition so high that it contributes to limited practice
opportunities? Have dental school curricula been watered
down to meet the demand of technology over technique? Is
there too much information for a four-year curriculum?
underprepared for the dental world of 2012, actually desire
mentorship. They are being mentored by self-proclaimed
institutes, emporiums of continuing education, and dental
businesses that offer employment and systems. They are also
mentored by manufacturers and dental supply companies
that promise personal wealth, but actually seek corporate
wealth. They are mentored by slightly older dentists who
have themselves been seduced into thinking that dentistry
is a business and not a profession.
It seems that the classic mentoring pattern of young dentist/
old dentist is changing to new dentist/financially successful
young dentist, new dentist/promises of wealth, and new den-
tist/corporate management.
Mentorship may well hold the key to the future of dentistry.
Young dentists might well question the origins and virtues of
the profession of dentistry. They might go back to the roots of a
great profession to discover why they have a great opportunity
and what they need to do to preserve that treasure for them-
selves and the future.
Associations provide many valuable services, but the
larger they are, the slower they adjust to and embrace change.
Associations do not want to lose members, and they choose
litigation issues very carefully. The ADA relies on state and local
dental organizations to self-regulate. The local associations
seem to rely on the larger group to take the lead. There is more
reaction than pro-action. Change is so gradual that by the time
it is recognized, the newstatus quo becomes acceptable and
perhaps a newstandard. Nowis the time to make clear state-
ments of standard of care.
Continuing education used to be a proud system of dissemi-
nating valuable knowledge; it involved teaching and learning.
CE has nowbecome big business with orientation toward profit.
The suppliers (formerly teachers) have discovered huge profits
with glitzy presentations that promise big profit for the practi-
tioner. Too often, the expensive products that are sold at the
emporiums of CE have the same level of value and integrity for
the practitioner as the new procedure has for the patient:
overpriced, over-utilized, and under-needed.
But the practitioner now has a fake certificate, initials to
use unethically after their name, a marketing package, and
the promise of a great profit center.
Technology and gadgets are displacing technique and
precision. There is no question that technological advances
have made immeasurable contribution to dental healthcare.
There is risk that the purchase of an expensive gadget obliges
its use and might even drive the treatment plan. There is also
risk of believing that if the technology is high-tech enough and
expensive enough, it will compensate for operator shortcomings.
Technology is not better than proper diagnosis, treatment plan-
ning, and accurate and appropriate implementation.
21 WWW.INDENTAL.ORG
A Better Prognosis
What is the big deal about being a profession, especially if
it interferes with business success? To begin with, the profes-
sion of dentistry has, for a century, been compensated at the top
of income levels. How much more wealth do you need or want,
and what are you willing to give for it? Being a professional
enables you to serve and continue to serve the healthcare
needs of patients with evidence-based treatment. Undue focus
on profit, production, and the temptation to market falsely dis-
tracts from the goal of healthcare (treatment of the clinical need
and being a doctor). Retail businesses are competitive and statis-
tically dont last. Atrue professional can practice for decades,
continue to care for thousands of patients, and accumulate
great wealth for his or her family. Adental professional enjoys
the trust and respect of society, government, and his or her com-
munity. That is invaluable and cannot be purchased or stolen.
It sometimes feels like no one cares, and nothing is being
done to save the profession. Dentists are so busy, work so hard,
and lead such complicated lives that little details like profes-
sionalism and ethics generally warrant little attention. The
concept of professionalism has been distorted to the point that
it is not recognizable, and fewhave noticed. But some things
are being done to save the profession of dentistry. Hopefully,
it is not too little, too late.
The Indiana Dental Association has taken steps to reactivate
the crucial Council on Judicial Affairs. Although the Council on
Peer Reviewand the Wellness Committee are likely the only
active demonstrations of self-regulation, they are highly effective
and have become national models. The IDAhas taken inten-
tional steps toward leadership training. Immediate-Past IDA
President, Dr. Terry Schechner, appointed a Taskforce on Ethics
and Professionalism that has been very active in developing
diverse, innovative, proactive, and positive (as opposed to puni-
tive) systems to enhance professionalism. The IDA has been
active in their support of other group efforts in the ethics arena.
The Indiana University School of Dentistry, under Dean
John Williams, is acutely aware of the problem and is making
significant efforts. IUSD has had a history of strong ethics cur-
ricula and remarkable synergy with the IDA and other dental
groups. Significant efforts are made to provide counsel and
preparation for practice. The white coat ceremony for the
new freshman is an effective orientation to professionalism.
Two years ago, a student-driven program called the Student
Professionalism and Ethics Association (SPEA) was formed.
Indiana students are on the forefront with an active group and
two national leadership positions. Dean Williams has already
provided generous financial and enthusiastic support.
The new generation of dental students is enthusiastic about
the profession of dentistry. Their knowledge of ethics is aston-
ishing. They yearn for guidance and mentorship, but they have
proven to be industrious on their own. They form student ethics
groups and eagerly attend meetings, despite busy schedules.
They will be fed one way or another.
The Indiana Section of the American College of Dentists,
with the support of the national ACD, has embarked on an
innovative mentoring program with a generous grant from
the national ACD organization. It will be structured and formal
in nature from a students senior year until five years after grad-
uation. A training program for mentors and mentees is being
developed. The goal is to develop lifelong relationships that
enhance the professional and ethical practice of dentistry.
The Indiana Section of the International College of
Dentistry has been actively implementing a national ICD
program of student mentorship called Great Expectations.
This professionalism program is designed to guide the begin-
ning dental student toward a more professional attitude and
behavior through peer influence.
Small groups are making efforts to save the profession,
but they lack the critical mass; too much has been allowed to
change over the past 20 years for only a small collective group
to address. Only a groundswell of professionals can save den-
tistry from the fate of being a retail industry. I am reminded of
the poem by Reverend Martin Niemoller:
In Germany they came first for the Communists, and I
did not speak up...Then they came for me, and by that
time no one was left to speak up.
You no longer have the luxury of dismissing the importance
of being a professional or delegating the responsibility for
action to others. Dentistry can only be saved from the fate of
the retail industry by the collective action of a critical mass of
dental professionals.
What Can You Do?
First, begin with yourself. All IUSD students are familiar
with the six Expectations of the Professional from Rule/Bebeau,
Quintessence, 2005:
1 Acquire the knowledge/skills of the profession to the
standard set by the profession.
2 Continue learning as new advances and technologies
emerge.
3 Put the oral health interests of patients before self.
4 Abide by the professions code of ethics.
5 Serve society (not just those who can afford your care).
6 Participate in personal self-regulation, the monitoring of the
profession, and participate in professional associations.
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Second, look to the future by nurturing professionalism in
others. The responsibility of mentorship should be number 7
on the Expectations of the Professional. Let your associations
and study clubs know that you value professionalism. Educate
your patients about the ADA Code of Ethics and Professional
Conduct, and encourage them to walk away from dentists who
do not measure up.
Third, there are good reasons to have legal and ethical
requirements to report unethical behavior. It is part of self-
regulation, and if you turn away and I turn away, that behavior
becomes acceptable as the peer standard. No one knows better
than you what is going on in your dental community, and no
one is in a better position to see that something is done about it.
Give the benefit of the doubt and call your colleague. If the
response is not appropriate, consult your local dental society
or the IDA.
If you see little value in the profession and dont care about
its future, take your money and pretend that it is someone elses
problem. Or if you never really thought that dentistry was a pro-
fession, and you were always smug about falsely reaping others
rewards, then lie and cheat every chance you get. See how
much that you can get away with before you get caught. Some
individuals are so smart that they can kill the Golden Goose and
still be proud.
Most have not realized the gravity of our situation and have
not appreciated the value of being part of a profession. Most
have been so busy making an excellent living that they forgot
they never could have been successful, had they not been con-
sidered a professional. I fear its too late, but I hope that I am
wrong. The change can begin with you, and it can begin today.
About the Author
Dr. Richard E. Jones is a retired prosthodontist from Schererville,
Indiana. He currently serves as Chair of the Indiana Dental
Associations Ethics and Professionalism Task Force, and Chair
of the Council on Peer Review. In the past he served as Chair of
the Indiana Section of the American College of Dentistry.
INSURANCE CONTINUES TO IMPACT
THE DOCTOR-PATIENT RELATIONSHIP.
THREES
A CROWD
Terry G. Schechner, DDS
Does my insurance cover this procedure?
How many times have your patients asked you
this question? You recommend a treatment plan
based on sound clinical judgment that best fits
the needs of your patient, and the patient is
dependent on the disposition of an insurance company that
bases its treatment recommendations on factors other than
the needs of the patient.
The patient will generally take the recommendations of the
insurance company over yours, because they are given infor-
mation regarding your fees being too high, or perhaps the best
treatment method is simply too expensive for them at the time.
The insurance companies have convinced the patients and,
more importantly the lawmakers, that they have the patients
best interests at heart.
Howdid we evolve to a point where the well-educated,
caring dentist has been essentially taken out of the loop in
determining the best treatment for our patients?
Dental insurance companies started providing benefits in the
1960s and 1970s, which quickly became a popular part of bene-
fit packages provided by employers. The benefit packages con-
sisted of $1,000-$1,500 annual benefit cap with various levels of
deductibles and co-pays, and some even provided orthodontic
coverage. In the beginning it appeared to be a good deal for both
patients and dentists. The patient would not have to come up
with a large down payment out of pocket, and the dentists cash
flow was improved by the influx of regular insurance money.
Some dentists tried to warn the profession about the dangers
insurance companies might pose in regard to diagnosis, treat-
ment, and fees. All one had to do was look at what was happen-
ing in medicine. The first sign that the insurance companies
were trying to be more influential in patient treatment deci-
sions came when they started demanding pre-op diagnostic
X-rays. The insurance companys dental consultant had to
examine the X-rays before approving coverage for the suggest-
ed treatment. In some, if not many, cases, they proposed the
least expensive alternative treatment, or LEAT, for the patient.
Isnt it interesting that, with very few exceptions, antitrust
laws do not prevent the insurance companies from doing any-
thing they want to do? They are partially protected from the FTC
and antitrust lawsuits by the McCarran-Ferguson Act passed in
the 1940s to protect insurance companies, big and small.
23 WWW.INDENTAL.ORG
Many dentists believe that some insurance companies also
use X-rays as a tool to delay payment for services already ren-
dered. Most states have laws mandating that insurance compa-
nies settle claims within 30 days of receiving a claim. In some
instances the insurance company will issue a request for X-rays
or other information on the 29th day, which immediately gives
them another 30 days to hold on to the dentists payment.
The next stage in gaining control over dental practices and
maximizing profits was the creation of managed care networks,
where the dentist signed a contract agreeing to discount their
fees up to 20% in order to participate. The ADA has published
data from membership surveys that the average dental office
overhead is around 70%. There is a concern that high overhead
can lead to shortcuts in treatment, use of inferior materials, or
even the rendering of little to no care to the patients enrolled in
these plans.
Starting in the early 2000s, the dental insurance companies
developed a new strategy for forcing dentists to enroll in their
PPOs. The plan was simple: If the dentist was not in the plan,
the insurance company would stop honoring the assignment
of benefit designation made by the patient. Almost all universal
insurance forms have a line where patients can sign and have
the payment sent directly to the dentist, or to themselves. The
vast majority of patients will direct that the payment be sent to
the dentist. Some insurance companies would ignore the
patients wish of where to send the money and send it directly
to the patient. This caused a considerable amount of confusion
for the patient who suddenly received a check from the insur-
ance company, all while the dentist received no notification of
payment made or the explanation of benefits (EOB). The dental
office would call the insurance company and find that payment
had been made to the patient. When the patient was called,
they believed the payment was an insurance refund. Many
times the patient had already cashed the check and still owed
the dentist their full fee.
The long-term effects were that the dentists cash flow was
disrupted, and collection fees increased. Another side effect of
the tactic was that the un-enrolled dentist did not receive the
EOB and could not file for any secondary insurance. Many den-
tists relented and signed up with the insurance companys best
paying plan. The net result was that the insurance companies
increased their managed care networks and could point out to
lawmakers that their network was popular with dentists, and
that they were saving consumers millions of dollars.
A new ploy for the insurance companies to maximize profits
for their stockholders is non-covered services. The insurance
company dictates to dentists enrolled in their plans what they
can charge for services not even covered by the insurance com-
pany. Some dentists believe that the limitations on charges are
formulated without regard to what a particular service actually
costs to provide. In addition, there could be more and more
services dropped out of coverage, but the fee is still set by the
insurance company.
Coordination of Benefits is yet another clever moneymaker
for dental insurance companies. For dentistry, if there are two
dental insurance policies, the primary plan will pay, but the
secondary may have a clause that states that since one insur-
ance plan has paid, there will be no duplication of benefit.
The full premium is paid for both policies, but the benefit is
only truly paid by one. There is no refund of the portion of the
premium that cant be used as a benefit; therefore, the insur-
ance company keeps it as pure profit.
Two is company, three is a crowd has been an expression
used for years to describe intimate relationships. The company
should be the dentist and the patient. Over the past 40 years,
the insurance companies have slowly interjected themselves
further into that relationship and, in some cases, have materially
impaired it. Insurance companies dont go to school for eight
or more years to learn about dentistry or patient care. Patient
care is not their mission, profits are.
The benefit caps have not kept pace with inflation, but the
premium increases have. There have also been more restrictions
placed on these meager benefits. The dentists have tried to
remain true to the relationships with their patients. We have
gone to the legislature to fight for our patients. The only arena
where we are allowed to promote a united voice for dentistry
is the Statehouse.
During the past six or seven years, we have made little head-
way. The insurance companies have well financed lobbyists
who can outspend us at every level. Their message is that they
are fighting for the patients to keep costs down. The patients
have often sided with the insurance companies because we
have been portrayed in the media as rich, uncaring health prac-
titioners. We need to become better advocates for ourselves at
In the beginning,
dental insurance
looked like a good deal
for patients and
dentists alike, sparing
patients from large
down payments while
improving dentists
cash ows.
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Fortunately since those early beans and rice days of practice,
we have been able to choose CE courses not based solely on the
investment necessary to attend, but the investment we hope to
gain for our personal development, our dental team members,
and most importantly our patients.
How we select CE courses depends on several different factors,
including cost, location, the speaker, the topic, and time. The most
important common denominator usually is topic: We dont know
very much about something and would like to learn more about it.
Dentistry is extremely dynamic, and new technologies and tech-
niques are being introduced at a very rapid pace. When we were
in dental school, the curriculum didnt include probiotics, lasers,
or cone beam radiography. Quite simply, if you want to learn about
any new innovations, you have to seek them out.
Our education at Indiana University School of Dentistry was
excellent; there is no denying that. But dental school should
never be the endpoint to our educationalways the very begin-
ning. Fortunately for us, and for any member of our profession,
there is a plethora of CE styles from which to choose that meet
any time or budgeting restrictions.
The Internet Factor
Howhas CE changed for us since we entered the profession
in 1999? We almost sound like we are from the dark ages by
admitting this, but in all reality computers and the Internet did
not factor much in our dental education. The Internet and asso-
ciated technologies have changed CE accessibility and
participants engage the content. It is hard to imagine sitting
in a CE class without at least one persons smartphone ringing,
or the ding-ding of an incoming text message. Social media
networks keep us connected to each other and make informa-
tion available almost instantaneously. With a smartphone
you can take notes during a lecture, take photos of slides, log
important dates, keep track of CE credits and, at the end of
the day, send a Facebook request to a former classmate with
whom you were able to reconnect at the courseor connect
with a new colleague you were able to meet.
When registering for the Rocky Mountain Dental
Convention, held in Denver Colorado this past January,
everything was done electronically. There was even a mobile
application to register for and log CE, get updates on room
changes, find details about lectures and social events, and
even peruse vendors participating in the exhibition hall.
Anew challenge to dentists seeking CE is to be aware of
patients access to the innovations in dentistry. For the most
part, information about new treatment options is also available
to our patients. The public seeks information on the Internet,
so it is vitally important that we stay current on the latest infor-
mation to adequately answer our patients questions and needs.
Our patients might not know or understand applications of lasers
in a dental practice, but most want to be reassured that their
both the state and national levels. We need to get the insurance
companies antitrust exemption repealed. We need to convince
lawmakers that the insurance companies put profit for the
stockholders over patient care and safety. All of us must partici-
pate and become engaged in the legislative process.
The uncertainty of how all of these issues will evolve
under the Affordable Care Act remains. The law encourages
the expansion of state Medicaid programs, but the Supreme
Court decision on the law prevents the federal government
from imposing expansions on states. Adult dental Medicaid
may continue to be optional, and the increases of visits to the
emergency room for dental disease will continue to be an issue.
Dental insurance interference will continue, until we fight
hard enough to take back control. Every one of us must recog-
nize what the future will hold for those who follow after us in
dealing with third-party payers. Understand that your decision
will be the legacy that is passed on to those who follow, even
your own children who may choose to become dentists. You
must get involved and help take back our profession from the
insurance companies.
About the Author
Dr. Terry G. Schechner practices pediatric dentistry in Valparaiso,
Indiana, and serves on the Indiana Dental Associations Council
on Governmental Affairs and Committee on Insurance,
Retirement, and Relief. Dr. Schechner also served as the 153rd
President of the IDA.
CONTINUING
EDUCATION
Karen E. Ellis, DDS
Jeffrey A. Stolarz, DDS
Immediately after graduating from dental school,
a time when most new dentists shudder at the
idea of sitting through yet another class, we
always enjoyed going to a dental lecture. We love
continuing education. As wide-eyed, eager,
novice dentists with concerns of how to pay student loans, mal-
practice insurance, and basic living expenses, the goal was
always to find the least expensive CE courses available to fulfill
the licensure requirement. Every reader knows that means free
and, admittedly, sometimes that was even too expensive!
25 WWW.INDENTAL.ORG
dentist is staying current with new technology. A young mother
may search online for information regarding oral health and how
that can affect her unborn child, but she will certainly come to
you, her dental provider, to help her understand the content she
has read. For all of the good information that is available, we know
all too well there can also be misinformation. It is our responsi-
bility to assist our patients with sorting out fact from fiction.
The Internet also ties us to the medical community. As we
learn more about the relationships of systemic and inflamma-
tory diseases to the oral cavity, online resources are a valuable
tool to educate ourselves and patients on those connections.
Sometimes all it takes is a quick Google search to learn about
a newmedication a patient is taking, or a disease with which
we may not be familiar. It is much more convenient having the
Physicians Desk Reference (PDR) or pharmacology resources
online, as they are continually updated and current.
Also demonstrating a positive benefit of the Internet to our
ability to learn is the ADA365. This is a fantastic way to partici-
pate in the American Dental Association Annual Session if you
are unable to travel to San Francisco for the live presentations.
From your computer, you can stream recorded video content,
and if you happen to be watching it live, there is the ability to use
a chat application to ask the speakers questions in real time.
Evidence-Based Dentistry and Live Courses
Another change in the new landscape of dental CE is the
concept of evidence-based dentistry. Discussions in courses
arent founded in hearsay or opinions but in the idea that
research is used to guide clinical decision-making; therefore,
the practitioner can provide the best care for patients. First,
this approach makes sense, and certainly a class has more
credibility if the information given is based on research and
not on the sales need of a particular company.
During our sophomore year of dental school, Dr. Charles
Tomich took our Oral Pathology class to the Indiana Medical
History Museum on Vermont Street on the near west side of Indi-
anapolis. Yes, a field trip in dental school was pretty awesome,
and still is. (I am sure we all felt a collective relief to be spared
from the dreaded assault of Clinical Correlations!) We wont forget
the formaldehyde-filled jars holding preserved specimens from
years ago in the pathology lab, but in touring the museum we
were also struck by the beauty of the teaching amphitheater. One
can imagine a professor performing dissections on a cadaver or
teaching on a variety of topics in this atmosphere.
This teaching method from years ago is resurfacing in
an updated modality in the form of Dentistry in the Round,
which is returning for the third year at the American Dental
Association Annual Session this year in San Francisco. On the
floor of the exhibition hall, dentists can go to a modern version
of the Medical History Museum teaching amphitheater. There is
a completely functional dental operatory where live patient
demonstrations are done by some of our industrys top clini-
cians. For example, this year you can see Dr. Gordon
Christensen demonstrate Class II Resin placement, or Dr. Jon
Suzuki perform soft tissue augmentation. Seeing new proce-
dures performed live is a highly effective learning method.
Back for the third year at the ADA Annual Session is the
Open Clinical Science Forum. These are great opportunities
if you want a short course (usually one hour in length, or one
CE credit) packed with a great deal of information. These are
open panel discussions on current dental topics with the latest
research, hosted by members of the ADA Council on Scientific
Affairs. The Council brings in authorities and lead researchers
on topics like fluoride efficacy and osteoradionecrosis of the
jaw. The discussions amongst the researchers are always lively
and include equally engaging question-and-answer sessions.
It is a great way to stay current on hot topics in dentistry.
What Worked for Us
When we were asked to write this article, we were invited to
share which courses have had the most impact on us personally
and professionally. We certainly agree that the American Dental
Association Council on the New Dentist Annual Conference was
not only pivotal in our careers, but perhaps has been some of
the most important CE in which we have participated. The New
Dentist Conference is geared toward clinicians in practice ten
years or less. (At this point you have done the math and yes,
it is true, we have exceeded the cut off. But dont tell...as this
is a meeting we will both continue to attend!) As recent gradu-
ates we found this was a perfect conference to attend, because
we could get 10-12 hours of CE over a weekend, didnt have to
take much time off from work, and the registration fee was low
and included all of the CE, social events, and meals. The lec-
tures have been different every year, but always with leaders
in our profession with subject matter aimed toward issues a
young dentist may encounter. The conference has always had
a relaxed environment, providing ample opportunity to learn
from each other and ask questions. As a result of these confer-
ences we have a network of friends across the country.
One of the benets of
organized dentistry is
that it will always give us
the resources we need
to stay current.
26
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FALL 2012 VOL. 91, NO. 3
We have also found that it is always best to participate in
a variety of CE offerings. DVDs are great, but perhaps go to a
hands-on workshop, too. CE courses on practice management
are valuable, but certainly try to take clinical courses as well.
CE is all around us; you really dont need to try that hard to
find an educational opportunity. There are online courses, live
CE and webinars, newsletters and journals, local study clubs,
dental lab-sponsored CE, institutional learning centers (i.e.
Kois, Pankey, LVI, etc.), and dental organization-sponsored
CE (i.e. ADA, IDA, AGD, AAWD, etc.) offered at local, state,
national, and international levelsjust to name a few.
Another great CE opportunity that we both participate is
the IUSD/IDA Academy of Continuing Education. The Academy
meets twice a year and offers great speakers at a very afford-
able tuition. Through this venue we have had the opportunity
to hear Stanley Malamad, Peter Jacobsen, and Carl Misch.
The speakers are always impressive.
We certainly dont see anything wrong with getting CE from
online courses, journals or DVDs (ask us about our VHS collec-
tion of veneer preps, rotary endodontics, or mandibular
anesthesia collecting dust!), but for us the benefit of going to CE
is networking with colleagues. Getting out of the office is good
for the spirit, and actually sharing stories and ideas is a very
important component of educational development. You begin
to realize that everyone has the same challenges. We can learn
so much from each other.
It is the networking with others, helping each other with
personal and leadership development and, most importantly,
the camaraderie with others that make actually attending CE
special. Dentistry can be isolating at times, and it always helps
going to a class to be around others and share experiences.
Another benefit in getting out to a class is because often
times leaders in our profession are also in attendance, and you
can interact with them and give input to issues you feel are
important. At the New Dentist Conference, the ADA President,
President-Elect, and Regional Trustees are all in attendance.
What better way to get involved than to have one-on-one con-
versations or lunch with these leaders! And they listen. Going to
CE is not only important for what you receive from a lecture,
but for the exchange of ideas that takes place among col-
leagues. The friendships we have made along the way have
been as invaluable as the clinical knowledge we have gained.
What Does the Future Hold for Dental CE?
It is hard to knowwhat CE will be like in the coming years,
but with the expanse of research being done, development of
new technologies, and the great leadership of our profession,
it will be exciting. One of the benefits of organized dentistry is
that it will always give us the resources needed to stay current.
We will probably continue to gravitate toward more hands-on
workshops and live presentations, but also look forward to the
possibilities of courses involving simulation models such as the
new simulation laboratory at IUSD. The important thing for all
of us is to just get out there, recharge our learning batteries, and
find a course that inspires and recharges us for our patients.
Keep learning. And hopefully, we will run into you at a course
in the future!
About the Authors
Dr. Karen E. Ellis practices general dentistry in Indianapolis,
Indiana.
Dr. Jeffrey A. Stolarz practices general dentistry in Whiting,
Indiana, and is a member of the Indiana Dental Associations
Council on the New Dentist and Council on Dental Benefits.
DIVERSITY:
A NEW
COURSE
FOR IDA
LEADERSHIP
Steven P. Ellinwood, DDS
Ask a group of people to define the term leader-
ship, and you will discover that each person
has a unique, personal definition. A persons
view of leadership has deep roots in his or her
experiences related to generational differences,
gender, region, and even personality style, only to name a few.
Without acknowledging, understanding, and engaging these
differences in a respectful way, we fail to unlock an individuals
ability to effectively lead.
As we have watched the practice of dentistry evolve
across the years, so have we watched the faces among our
Associations membership diversify. We must understand the
strengths this growing number of differences might bring to
organized dentistry, as well as how we can put these strengths
to work for the profession, if we are to survive the many chal-
lenges we currently face.
27 WWW.INDENTAL.ORG
Perhaps the most significant change we must be willing to
make is to embrace the ever diversifying population of dentists
in our state, specifically ethnic and gender diversity. White
males have predominantly occupied the dental profession for
many years; however, if you look at this years freshman class at
Indiana University School of Dentistry, 52% are female, and
11% identify themselves as an ethnic minority.
For too long, the assumption has been that there should be
no change to the IDA association model, and that each years
newcrop of dentists will fill the existing leadership roles as in
the past. This thinking has actually worked for many years, but
our world has changed. New dentists volunteer time may be
filled with projects not related to our profession. Or, they might
not viewthe ADA, IDA, or local dental society as their represen-
tative in the dental community. To view these increasingly com-
mon values negatively does not take into account the individuals
experiences. For example, certain individuals may have always
felt they were on the outside of large organizations and seek out
smaller peer groups. They may feel their concerns are not as
global as the ADAor IDA, and wish to focus on improving gen-
der, ethnic, or general dental issues in their own communities.
The change is already here, but how that affects leadership
is yet to be identified. As there is little time to prepare and
adapt, we must be nimble in embracing and engaging the
positive impact these trends can have for our Association,
our profession, and ultimately our patients. It is in everyones
best interest to find out what we must do to ensure new dentists
will join our organization, and then feel compelled to carry
the torch for the profession as leaders.
About the Author
Dr. Steven P. Ellinwood practices general dentistry in Fort Wayne,
Indiana, and serves as Assistant Editor of the Journal Indiana
Dental Association. Dr. Ellinwood serves on the Indiana Dental
Associations Council on Communications and is Chair of the
Leadership Development Committee.
Generational Differences
There is a remarkable amount of literature defining the cur-
rent categorization of generational groups in the United States,
which sometimes confuses more than enlightens. We can all
accept that it is unfair to completely stereotype one generation
from the next, but co-authors of Race for Relevance, Harrison
Coerver and Mary Byers, compiled studies that generally indi-
cated Baby Boomers expect to lead, while Generation X overall
has less desire to leadMillennials value teamwork and are the
ultimate multi-taskers. Yet we still cannot force all individuals
into their respective generational boxes. Having insight into the
core values of a generation can be very helpful. Yet, the following
statement from Race for Relevance might be the organized den-
tistrys most important warning about generational differences:
With each succeeding generation, there appears to
be a growing disconnect with trade associations and
professional societies.
What are we to do with such a statementaccept our demise
and run for the hills? Not quite. We can and must work harder to
energize the younger generation of practitioners to become active
in our dental societies. These individuals are energetic, intelli-
gent, and tech-savvy in ways most of us are not; we need them.
It is also pointed out in the book, and we all have experi-
enced this, that there seems to be less and less time. In our fight
for efficiency in work, family life, and community involvement,
we have only created a growing checklist of items that never
seem to all get accomplished. Any member, especially those
who are involved at any level of organized dentistry, will tell
you that they love helping lead our professionbut its some-
times impossible to find the time. No generation is exempt from
this trend; none of the new technology has been able to slow
down our lives. Acknowledging this trend, we must not only
seek to provide new opportunities that make effective use of
volunteers time, but we must take a hard look at our existing
activities and be honest about where time is being wasted.
GENERATIONAL DIFFERENCES
GENERATION YEARS OF BIRTH
Baby Boomers 1946-1964
Generation X 1965-1981
Generation Y
(Millennials) 1982-1999
We must be willing
to embrace Indianas
ever-diversifying
population of dentists,
specically ethnic and
gender diversity.
28
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FALL 2012 VOL. 91, NO. 3
Many students do not enter dental school having a solid
idea of what they want to do at the end of the four-year curricu-
lum. Students wishing to specialize need to take the time to
understand all of the criteria necessary to be admitted into the
specialty of their choosing. For example, creating a vision of
what it will be like to be a specialist is key in getting through the
rigors of a difficult program. This includes the investigation,
observation, and extremely hard work necessary for success.
Similarly those electing to practice general dentistry (which
accounts for about 83% of the graduates) need to explore how
to best begin in that field. There are many options, which will
be discussed later in this article, but investigation into the pros
and cons of each choice is essential from an early time to be
able to optimize success and satisfaction.
An ADA survey in 2003 showed that only 5% of dentists had
enough money saved from their practices to retire. For a myriad
of reasons, this survey shows that even with time and experi-
ence, there is no guarantee for success. The blessing for many
dentists is that they are not forced to retire at age 65, yet I would
imagine that most would like to at least have the option. I per-
sonally know many dentists who have practiced well into their
seventies to maintain their desired income levels.
In a 2010 ADA survey of dentists 40 years and older, the aver-
age age for dentists to retire is trending up and is now at about
66.9 years of age. (Interestingly, when asked the same question of
proposed retirement to dentists under 40, most thought they
would retire around 60 years of age.) This is essential knowledge
for the student, as there may be fewer opportunities to start a
practice than there were in previous eras of graduation. As a mat-
ter of fact, a study of 2008 graduates showed that only 8.6% of
graduates actually start out owning their own practices. If one of
the major reasons that dentists are practicing later in life now is
from a financial shortfall, then what was not learned along the
way to enable these professionals to be able to retire when most
every other occupation has members who are able to do so?
There are two glaring omissions in todays dental school
curriculum: business education and soft skills. With all of the
technical and science requirements, it is difficult to know how
to more integrally insert these two needed topics in an already
packed program.
Whether we are willing to admit it or not, health care is a
business. While we do not know what the future of the health
care industry will be, it is certain that there will always be room
for the entrepreneur. The dental student currently has limited
experience in what it takes to run a business. Although there is
an extramural requirement in order to graduate, most take the
time to look at materials and technique rather than determine
how things are ordered, how staff is managed, or how to read a
profit/loss statement. I would also suspect most mentor dentists
would not be forthcoming in sharing those items with a student.
THE BUSINESS
SIDE OF
DENTISTRY
Thomas R. Blake, DDS
None of the issues shifting the foundations
of Indiana dentistry will be more important
than those affecting students currently studying
to become dentists. While the future of dentistry
is in their hands, practicing dentists share in the
responsibility to maintain the respect that our time-honored
profession has gained over the years. Whether a student, recent
graduate, or grizzled veteran, we all play a part in the scenarios
currently occurring in dentistry.
One of students most critical barriers to enjoying the profes-
sion as much as we have is the amount of educational debt
acquired by the time they graduate. In an ADA survey of 2008
graduates, it was found that almost 93% of graduates had edu-
cational debt upon graduation and 64% had additional debt.
The average debt for graduates had risen to $240,000 in total
debt, with the educational debt accounting for 75% of this load.
Over the four years preceding, the average debt had increased
by $55,000. Of course, this debt does not include purchasing
a practice, home, or equipment, if that is the course the gradu-
ate chooses. Due to this factor alone it is important that, early
in a students career, he or she develops a plan for managing
debt and transitioning successfully into practice.
One of my favorite books, The Seven Habits of Highly
Effective People, written by the late Steven Covey, is certainly
applicable to the young student in school. The two most impor-
tant habits for students are to first be proactive, and second
to begin with the end in mind. Most students come into school
focused on all of the science and technical skills that will be
required to pass boards and gain licensure, but no matter how
intelligent or what kind of hands the student has, there is no
direct connection to financial success.
Most first-year students do not even think about the fact that
they will be running an actual business that will provide a living
for themselves, their families, and their employees. Proactivity
means a student is beginning to look at opportunities from day
one of dental school. It is the responsibility of the older dentist
to help the younger dentists find these opportunities. We are
fortunate at Indiana University to have Dean John Williams,
who is fully aware of the fact that todays students will be run-
ning tomorrows practices and is doing everything he can to
assure those students success.
$
29 WWW.INDENTAL.ORG
If the extramural experience and the dental school do not
provide the tools for the aspiring dentist to organize and build
his or her business, how will a student learn? As evidenced by
the absurdly low percentage of dentists being able to retire and
the increasing age of retirement, perhaps the only way this is
learned is in the School of Hard Knocks and, even then, it must
not be being learned well. Students must be guided through vari-
ous viable business models and learn how to ascertain metrics
from the practice, such that financial independence can be
achieved. Many practices are out of control when it comes to
spending, because no one has ever taken the time to know what
prudent spending is. I feel that these ideas are coming to light,
at least here in Indiana. Having as many dentists as possible
achieve financial success will be a step in the right direction in
keeping the dignity of our profession intact, and offices and
equipment that run at full capacity for our patients.
Students must also begin the process of mastering the
psychology of dentistry, or soft skills. Most successful dental
practices have taken the time to realize the importance of
creating and nurturing the relationships that occur among the
doctor, staff and patients. Many science-oriented dentists do
not have these traits naturally and have to develop them as they
mature in their practices. Once again, it is more than technique
that determines overall success.
The student gets practice at soft skills with a few patients,
but the relationship developed with the dental school patient
is not realistic in a real-time practice. No one is going to spend
two hours doing a Class I composite in private practice.
How does one nurture these relationships along the way?
As I always relate, how do you get good at free throws? Answer:
Shoot a lot of them. This is the same with patients, yet each
patient is an individual with a unique set of circumstances,
a unique personality, and a unique health history. There is no
singular way to relate with patients, but the doctor must sur-
mise what is best for the patient and be able to communicate
it effectively, such that the patient can achieve optimum
healthor at least understand what it takes to achieve it.
Reaching New Heights
There are many other considerations in optimizing chances
for success in dentistry, but many of them have to deal with
gaining experience and vowing to be a lifelong learner by seek-
ing quality continuing education opportunities. There are now
endless opportunities to learn more about subjects not ade-
quately addressed in four years of dental school. Once again,
older dentists can help lead the way in assisting the novice in
the search for quality programs.
Mentors: The Informal Advantage
While it would be ideal if there were lists of dentists willing
to help their younger colleagues in the profession, no solid pro-
gram formally exists. There are dentists who are more than
willing to share their knowledge to an eager novice. As Heinrich
Heine once said, Experience is a good school, but the fees are
high. An older mentor can help his or her mentee to avoid pit-
falls that can cause financial and emotional heartache.
Students would benefit by seeking out such a mentor early
in the educational processnot the day after they graduate.
My own dentist and I had a mentoring relationship along the
way, and I give him full credit for helping me establish my prac-
tice. Those who care about our profession and the greater good
are there for the asking. It would be ideal if mentors would
jump out to offer their services, but it is to the benefit of the stu-
dent to actually seek the sage, even if it is out of the students
comfort zone. These relationships generally continue to flour-
ish over time, as both mentor and mentee advance in
knowledge and experience.
Payback Time
Dental students realize that most of them will graduate with
significant debt, that most will go into general dentistry with lit-
tle to no business experience, and that the skill sets developed
in dental school will not be sufficient alone to guarantee long-
term success.
Regarding loans, todays students are faced with such
monumental debt that they feel the pressure to start making
significant money almost immediately.
Statistics from the 2009 ADA survey showed that 18.1% of
graduates owned their own practice, while 73.6% worked as
non-owner dentists. Over 8% of graduates actually work in a
second career and 33.1% of graduates work only part-time as
private practitioners. This part-time work figure is up dramati-
cally (14%) over the four years prior and over 22% (which is also
an increase over the prior four years) of that years graduates
went on to either graduate school or undertook a general prac-
tice residency (GPR). When combining the statistics above, one
Many students enter
dental school with
no solid idea of what
they want to do
at the end of the
four-year curriculum.
30
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FALL 2012 VOL. 91, NO. 3
can infer that a greater number of graduates are at least post-
poning owning a private practice, if not electing some
alternative business model.
The opportunity that seems to be the most advantageous
for graduates is to associate with an older dentist to gain experi-
ence. This too is the reason that many students are electing to
take a year in a GPR to learn more about different procedures
and practice. The associateship may present challenges, how-
ever, if the new and senior dentists are not clear about
expectations at the outset. Beginning with the end in mind is
certainly the most important thing to take into consideration
here, and there are professional transition experts who can
help to make the most advantageous work situation for both
parties involved.
Another avenue for the new graduate that has grown in
scope is the corporate model, where the new dentist is
employed by a larger dental company and has a financial stake
in the production that occurs in the office. While there is cer-
tainly a financial benefit to the new graduate under this model,
there is an expectation from the company that the new dentist
will be a profit center. Failure to live up to production standards
can lead to dismissal. New students looking into these opportu-
nities have increased in number, as has the presence of
corporate practices. One study has shown that at its current rate
of expansion, corporate dentistry will have a 17% share of the
market by 2018. The corporate model will be a force in the
dental market for the foreseeable future.
Educational debt and the myriad of ways to practice after
graduation require that the student look ahead to determine the
best path for individual success. Taking time to understand
business, as well as how to manage relationships with patients
and staff, are two skills not currently taught. These will need to
be learned in order to establish the successful practices of the
future. Knowledge of these transitions will enable us as a pro-
fession to be prepared for the next generation of dentistry.
About the Author
Dr. Thomas R. Blake practices general dentistry in Fort Wayne,
Indiana, and serves on the Indiana Dental Associations Council
on Communications and Finance Committee.
31
I have a large amount of practices where the dentist is in
his or her 60s and 70s practicing an average of three days a
week due to the economic downturn, Dawn said. It has defi-
nitely been my experience that dentists are returning to work
and delaying their retirement due to the economy and stock
portfolios.
The problem of not being able to find an associate or buyer
is also frequently seen in the practices Midway serves. Dawn
added, Ten years ago you saw dentists retiring at 60-65, but today
it is quite common to see a doctor working much past that age.
Dr. Crisis solution of remodeling and upgrading his office is
also becoming a more common practice. Dawn said she has
seen an upturn in doctors building or upgrading their offices at
a later age, occurring for two main reasons: First, they need a
better product to attract a smaller group of graduates and/or
younger dentists to buy their practice, and secondly they are
working longer, so the upgrades to newer, more technological
offices will attract more patients. The assumption of the doctors
is that by working for an additional 5-10 years, their investment
will reap the benefits.
Dr. Planners dilemma came up at the IDA House of
Delegates meeting in June 2012. A retired dentist who had let
his dental license lapse petitioned the state board to allow him
to sit for the hygiene licensure exam. He had been away from
dentistry too long to pass the dental exam, but he felt confident
he could work as a hygienist. Dentists are un-retiring to sup-
plement a retirement rocked by economic uncertainty.
In my first year in practice I hired a dental consultant
because of my total lack of business experience. Tom OBrien,
a salty old dog if there ever was one, had spent his entire career
in the dental industry. He had worked for dental supply compa-
nies for many years and was using his vast experience to help
young dentists get on a firm business foundation in their prac-
tice. For me, Tom was a lifesaver.
WWW.INDENTAL.ORG
THE UNRETIRED
DENTIST
The economic downturn has caused some dentists
to have to work beyond retirement age. This new
trend has an unexpected fruit: joy.
Michael D. Rader, DDS
Dr. Planner thought he had done everything right.
He had very carefully and faithfully invested in
his dental corporation pension plan. His Indiana
house and condo in Naples, Florida, were mort-
gage-free. Yet retirement was not turning out like
he had planned. First, the stock market downturn had shrunk
his retirement by 50%, and his home and vacation condo had
lost a lot of valueif he could sell them. Both he and his wife
are looking for jobs. Dr. Planner says, Im afraid that I will out-
live my retirement funds.
Dr. Crisis is 67 years-old and practices four days a week.
He works because he doesnt have enough money for his retire-
ment. Dr. Crisis said, First it was 9-11, then the Dot.com crash.
Next the housing bubble burst. My retirement account doesnt
seem to be growing anymore.
Dr. Disappointed would like to retire. In the past few years,
he remodeled his office, replacing the equipment with new
A-Dec chairs and dental units. He has been looking for an asso-
ciate to work in his office with the plan to sell his practice and
building. But, Dr. Disappointed cannot find a qualified buyer.
There didnt seem to be many who are risk-takers at that point
in their careers. These folks thought opportunity included a
guaranteed salary usually beginning at $100,000 a year plus
vacation and benefits, Dr. Disappointed stated.
Drs. Planner, Crisis, and Disappointed represent the
unretired dentist.
The 1970s saw a remarkable increase in the number of
dental graduates produced annually. Federal government pro-
grams addressing a perceived shortage of providers propelled
this increase. That group of baby-boomer graduates is now
reaching retirement age, and many factorsincluding some
unintended consequences of governmental policies, as well
as economic, societal, and cultural shiftswill strongly influ-
ence their retirement rate.
Dawn Metcalf, Sales and Marketing Manager at Midway
Dental Supply, has seen the newly emerging difficulties in
dentists retirement planning.
I would be bored
without dentistry.
The thought of playing
golf more than once a
year, let alone every day,
is frightening.
32
JIDA
FALL 2012 VOL. 91, NO. 3
The future dentist may extend his or her working career
longer than in the past. Whether forced by economic necessity,
or simply by the enjoyment of a fulfilling and rewarding career,
the working life of todays dentist will look very different then
his or her predecessors.
Ive come to learn that you spend some really wonderful
years gripping a dental handpiece and, in the end, you find
out it was the other way around all the time.
About the Author
Dr. Michael D. Rader practices general dentistry in South Bend,
Indiana, and serves as Associate Editor of the Journal Indiana
Dental Association. Dr. Rader also serves on the Indiana Dental
Political Action Committee.
WHAT DOES
IT ALL MEAN?
THE RACE FOR RELEVANCE
Mary M. Byers, CAE
Much has changed in the profession of dentistry since the
Indiana Dental Associations creation in 1858. When the IDA
was founded, who could have predicted the dominant issues
in the year 2012 would include universal healthcare reform,
ballooning dental education costs, third-party insurance battles,
and large group practice models?
The one thing that hasnt changed much over the years is the
way the Indiana Dental Association does business. Like many
professional associations, the organization is heavily dependent
on volunteers, dues revenue, and member engagement. Yet all
are decliningforcing the association to take a close look at
what the future holds for dentists in Indiana.
Heres whats challenging the Indiana Dental Association
and other organizations today:
Time Pressures
The lives of association members are increasingly complex,
affecting their ability to volunteer and/or access association serv-
ices. Symptoms include poor attendance at council and commit-
tee meetings, decreasing utilization of continuing education pro-
grams, and an increasing number of members who dont renew
membership.
It seemed that Tom knew practically every dentist in the
state and was a notorious namedropper. Tom eagerly men-
tioned that he had consulted with a classmate.
Steve is now so busy that with his spare cash he has pur-
chased a roller rink as an investment, Tom said. He clearly
implied that if I followed his advice I, too, could be a captain
of commerce.
While hopeful that Toms wisdom would magically grow
my practice, all while feeling a bit envious of my classmates
quick success at the same time, it struck me as being a bit odd
that, time and time again, Tom cited Steves business triumphs
outside of dentistry and how soon he would be able to retire.
I could not understand why dentists, who had worked so hard
to be a success in dentistry, would gauge their success by how
soon they could retire.
I cant think of any profession where someone walks away
at the pinnacle of success. You certainly dont see professional
athletics do that; in fact, its usually the opposite. There exists a
growing group of dentists who want to continue to practice due
to the joy and fulfillment they find in their work.
Past IDA President Marty Szakaly said, I have found that I
love my profession more. I like getting up every day and going
to work. Id be bored out of my mind if I didnt have dentistry.
It was a while ago that I had a discussion along similar lines
with classmate Dan White. At the time, Dan and I had been in
practice for 18 years. I remember looking at Dan and asking,
Well, do you think we are half done with our dental careers?
Dan, giving me a weak smile, replied, I hope so. I think 36
years is enough. At the time I agreed, but not today. Dan, Steve
and I have practiced for 33 years, and frankly Immore both-
ered by the idea that I might have to quit some day. Like Marty,
I would be bored without dentistry. I dont have a hobby that
could possibly fill the time my job occupies. The thought of
playing golf more than once a year, let alone every day, is fright-
ening to me.
When my dad retired, within a year he had a part-time job
mowing greens at the local golf course. He liked the job because
it kept him busy, and he enjoyed working with the other greens
keepers (who were either kids on college break or retirees like
himself). He didnt like getting up at 4:30 a.m. and getting paid
$8.00 an hour. His experience of returning to work part-time so
soon after retirement will make me think long and hard about
my retirement plans. The thought of finding a job, any job, to
fill a void in my day makes the idea of reducing my practice to
maybe two days a week an appealing option.
If I want a part-time job why not be a part-time dentist?
After all, one of the great benefits of our profession is the
flexibility to work the hours you choose.
33
Value Expectations
With economic pressures mounting, members are looking
for a clear return on investment for their dues dollar. Associations
must be able to articulate and communicate a succinct value
proposition. Those that do will survive in the future.
Member Market Structure
Many associations are serving member markets that are
vastly different from those they were initially designed to serve.
For dentistry, this includes the increasing number of large group
practices and the move from private pay to third-party payers.
Generational Differences
While stereotyping is dangerous, its clear that each genera-
tion has its own values when it comes to volunteer service and
expectations regarding return on investment for dues dollars.
Differing experiences also challenge associations as they attempt
to be relevant to both those who grew up without computers
and those who have been using computers since childhood.
Competition
The number of associations serving industries and profes-
sions has grown dramatically, resulting in increased association
vs. association competition. A quick online search shows over 60
dental associations (not including state or local dental societies).
In addition, competition from the for-profit sector has increased
for virtually every association offering, from publications to trade
shows, to educational programs and products such as insurance.
Associations ability to compete with a wide range of product
and service providers is a new and considerable challenge.
Technology
Associations have been slow to adopt technology, and their rel-
evance is increasingly at risk if they dont bridge the resulting gap.
Atsunami of technologies has evolved to offer virtually every asso-
ciation deliverable and function: education, information, network-
ing, fundraising, grassroots mobilization, etc. Theres no ignoring
the fact that Facebook has 800 million members, YouTube views
now number over a billion daily, and more than a million mobile
apps now exist.
Five Radical Changes for Associations
In light of the above challenges, whats the secret to remaining
relevant? Todays associations are addressing the above challenges
in five ways:
qOVERHAUL THE GOVERNANCE MODEL
The typical associations governance structure and processes
are obsolete in todays environment. They are too big, too slow,
time-consuming, reactive, they underutilize the organizations
human capital, and they are expensive to run. Sound familiar?
Associations need boards composed for performance that can
govern nimbly and effectively, not boards composed by geogra-
phy, special interests, who one knows, or howlong one has been
around. A house of delegates that meets once a year makes it dif-
ficult to move an organization forward quickly. And a large house
of delegates makes it costly and time-consuming to govern.
wEMPOWER THE CEO AND ENHANCE STAFF EXPERTISE
With volunteer time pressures increasing, associations must
increasingly rely on staff expertiseand hire accordingly, both
in terms of the number of staff and the skillsets required. Overall,
associations have been reluctant to transfer responsibility to
staff, sometimes resulting in stalled or slowed projects, missed
opportunities, and responses that are too little, too late.
eRIGOROUSLY DEFINE THE MEMBER MARKET
What does the member of tomorrowlook like? How are their
needs different than the member of yesterday? These are key
questions for associations to answer.
For dentistry, this means asking how the needs of a self-
employed solo-practitioner differ from the needs of a corporately
employed dentist in a large group practice. Different model; dif-
ferent needs. What, if any, difference does this make in the
WWW.INDENTAL.ORG
Although much
has changed in the
profession of dentistry
since the IDAs creation
in 1858, the way the
IDA does business
remains the same.
Now the IDA must
take a close look at
what the future holds
for Indianas dentists.
34
JIDA
FALL 2012 VOL. 91, NO. 3
$250,000. Today, 800 firms pay $1,995 each to subscribe to
IBuild, producing annual revenue of $1.6 million. The project
has been so successful that the association was able to pay off
its loan for the project in just three years (despite a prediction
IBuild wouldnt be profitable for five or six years).
In 2003, Master Builders of Iowa made a bold decision:
The association would focus on what it identified as its core
capabilities, in combination with what members prioritized,
and let some products and services lapsea strategy thats often
overlooked in the association world. By narrowing its focus, the
association has been able to develop deeper, more meaningful
services for members, including project information and labor
relations services. Retention is up by 5% as a result.
Seeing a bleak future with fewer players in the market due to
mergers, acquisitions, consolidations, and company closures, the
National Association for Printing Leadership decided to concen-
trate less on overall market share and more on share of member.
The philosophical change internally moved the organization from
one with a questionable future to an entirely new association
model. The group now operates as a consultancy, hiring industry
specialists to partner with members. The organizations bleak
future is now much brighter. In 2010 the association predicted it
would generate $2.4 million in consulting revenue. More impor-
tantly, members are experiencing stellar returns as a result of the
associations consulting services, even in a challenging market.
Anewenvironment requires a newway of doing business.
To move into a future of prosperity, the Indiana Dental Associa-
tion must ask, Howcan we help members work less stressfully,
more productively, and more profitability? A solid answer to
that question will pave the way for Indianas dentistsand ensure
the association remains relevant in the future.
About the Author
Mary M. Byers, CAE, is a former state dental society executive and
a strategy and planning facilitator. Shes the author of Race for
Relevance: 5 Radical Changes for Associations and will again be
facilitating the American Dental Associations Mega Topic discus-
sion at this years House of Delegates meeting in San Francisco.
product and service line-up, advocacy, and continuing education
offered by the association? The answer(s) may change what the
IDA looks like in the future.
rRATIONALIZE PROGRAMS AND SERVICES
The typical association tries to do too much. For most, the
underlying thinking is that the more programs, services, prod-
ucts and activities offered, the more valuable membership is.
Yet volume does not equal value. Associations succeeding today
actually offer fewer products and servicesand only those they
can provide competitively.
tBRIDGE THE TECHNOLOGY GAP AND
BUILD A FRAMEWORK FOR THE FUTURE
For many associations, investments in technology have been
made slowly and begrudgingly. The average $4 million/year
association spends more on printing and food than it does on
technology (4.1% of total revenue; 1.6% if human resources
expenses are subtracted). New philosophy must acknowledge
the promise of technology and how it will be critical in position-
ing associations in the future. Fortunately, the Indiana Dental
Association appears to be well on its way to advancing this area
of its operation.
The New Environment
Associations thriving today are adapting tools traditionally
employed by for-profit companies, such as market research,
product testing, professional marketing, market segmentation,
and value pricing. Take a look at what this newmindset has
done for these associations:
The race for relevance at the Texas Trial Lawyers Association
required revamping membership categories. In doing so, the
association accurately predicted losing 35% of its membership
in the short run. Can you imagine recommending such a radical
change? Ultimately, the new member dues structure resulted in
doubling revenues and a retention rate that increased 8% three
years after the change occurred.
The New Jersey Veterinary Medical Association did what few
before it have: moved from geographically-based board repre-
sentation to competency-based representation, and the
organization decreased the size of its board to five members.
Both changes are the result of a close look at the reality of asso-
ciation management and governance today: Volunteers are
pressed for time, and associations are more complex than ever.
Many are moving from operations-focused to setting strategic
direction and evaluating overall performance, mirroring for-
profit boards more than a traditional association board.
Carolinas Associated General Contractors earmarked $1.2
million to create an Internet-based platform designed to pro-
vide a portal for members to bid on projectsin spite of a
previously failed effort that lasted 18 months and cost nearly
36
JIDA
FALL 2012 VOL. 91, NO. 3
CLASSIFIEDS
Classified ads for JIDA are $50 for the first 25 words and
$0.25 per additional word. The use of an association box num-
ber is optional for an additional $20. The Managing Editor
reserves the right to edit classified advertising copy for clarity.
Submit ads on the IDA website at INDental.org/Advertising.
POSITIONS AVAILABLE
Midwest Dental is seeking candidates for the greater
Indianapolis market. Since 1968, our philosophy of supporting
doctors and staff has led to unmatched consistency and paved
the way for future growth. We pride ourselves on providing
doctors the ability to practice in a traditional, non-HMO prac-
tice environment coupled with the flexibility and rewards a
group can offer. We are currently working on new opportunities
in the greater Indianapolis market. Wed enjoy the opportunity
to learn about your practice philosophy, career goals, and
expectations. To learn more, please contact Andrew Lockie
at 715.579.4076 or email alockie@midwest-dental.com.
Visit online at www.midwest-dental.com.
Established private dental practice in heart of Broad Ripple (Indi-
anapolis) seeking motivated dentist. 3+ years experience pre-
ferred. Digital X-rays used. Email CV to amdentalhr@gmail.com.
Dental Dreams desires motivated, quality-oriented associate
dentists for offices in IL (Chicago and suburbs), DC, LA, MI, MD,
MA, NM, PA, SC, TX, and VA. We provide quality general family
dentistry in a technologically advanced setting. Our valued
dentists earn on average $230K/yr. plus benefits. Call
312.274.4524 or email dtharp@kosservices.com. New
graduates encouraged!
Part-time dental assistant needed for thriving private practice in
Shelbyville, IN. Please email resume to amdentalhr@gmail.com.
Busy, state-of-the-art dental office in northwest Indiana
is looking for a smart, progressive, hard-working dentist
to join our team. We average 80+ new patients a month.
Immediate availability. If interested please email resume
to profitablehelp@yahoo.com or fax to 219.322.9986.
Looking for a career change? Do you seek autonomy and clini-
cal latitude? Join our group of practices and do the dentistry
that you want to do. Email your CV/resume to mdelaney@indi-
anagentledentist.com or call Mike at 317.847.0099.
37 WWW.INDENTAL.ORG
PRACTICES AVAILABLE
Exciting opportunity for dentists, hygienists, and assistants
to provide children with dental care in Indiana schools.
No evenings or weekends. Email your resume or questions
to jobs@smileprograms.com or call Judy at 888.833.8441 x102.
Pediatric or General Dentists wanted.
For more than forty years, Midwest Dental has served as a
trusted transition partner for practice owners seeking discreet,
efficient, transition alternatives. We offer vast experience in
supporting practice owners through the transition process. We
seek like-minded care providers with a vested interest in the
long-term health of their patients and the careers of their staff.
All discussions are strictly confidential. Importantly, we are a
dental practice so there are never any fees involved when work-
ing with us. To learn more, please contact Justin Wolfe at
312.720.1089 or email jwolfe@midwest-dental.com. Visit us
online at www.midwest-dental.com.
Large practice in 3,500 sq. ft. office space with 5 operatories
(expandable to 7). Very nice office with over 50 years of com-
bined goodwill. Over 2,000 patients seen the past three years
with average collections of $950K/yr. Owner dentist is moving
out of state. Buyers net of $284K after debt service. Email
bkegelske2005@comcast.net for more information.
Practice in northwest suburb of Indianapolis with 5 operatories.
Grossing $550K, net $225k in 3.5 days/week. Equipment and
decor new in last 5 years. Paperless/digital with Eaglesoft.
Equipment in excellent condition. Efficient hygiene recall sys-
tem, high treatment plan acceptance rate, awesome staff. A lot
of potential due to no marketing and referring out molar endo,
most ortho, 3rds extractions, and implants. Great opportunity
for continued growth and success. Over 2,000 active patients,
average 37 new patients/month. Owner is flexible with turnkey
or becoming an associate. Email towniedentist@hotmail.com.
IUSD graduate seeks like-minded general dentist to purchase
rural dental practice in Hawaii. Profitable office with assured
patient base, excellent staff, doing all phases of dental care
including pedo, oral surgery, endo and prosthetics. Full-time
practice (4 days) and full-time hygienist. Have time to enjoy golf-
ing, outdoor, and ocean sports and no snow! Must have Hawaii
license. Serious Inquiries may contact
HiDent1218@yahoo.com.
Apicture may be worth a thousand
words, but just 25 words will sell your
practice, get rid of that old equipment,
locate volunteers, find an associate...
Share a word or two with your colleagues when
you place a classified ad in Journal Indiana Dental
Association. Youll reach 2,900 dentistsyoung
and old, new and experiencedlooking and ready
to respond.
IDA Classieds
First 25 words $50.00
Each additional word $0.25
For your convenience, classifieds that appear in our publi-
cation and online may be purchased exclusively on the
IDA website at INDental.org/Classifieds.
38
JIDA
FALL 2012 VOL. 91, NO. 3
IN MEMORIAM
Dr. Donald W. Johnson (Carmel, member of the Indianapolis
District Dental Society) died July 1, 2012. Dr. Johnson graduated
from the Indiana University School of Dentistry in 1956.
Dr. Mark D. Lemons (Martinsville, member of the Indianapolis
District Dental Society) died June 16, 2012. Dr. Lemons gradu-
ated from the Indiana University School of Dentistry in 1985.
NEW MEMBERS
EAST CENTRAL
Dr. Lee B. Davis (IUSD 1981)
Dr. T. Jason Zigler (IUSD 2012)
INDIANAPOLIS DISTRICT
Dr. Craig A. Arive (IUSD 2012)
Dr. John W. Bailey, Jr. (IUSD 1998)
Dr. Alyssa Balsbaugh (IUSD 2012)
Dr. Jason A. Bayless (IUSD 2012)
Dr. Brian E. Brown (IUSD 2012)
Dr. Megan Byrne (IUSD 2012)
Dr. Devanshu Chowdhary (IUSD 2012)
Dr. Dennis S. Frazee (IUSD 2012)
PRACTICES AVAILABLE
MUNCIE, INOpen 4 days per week. Collections have consis-
tently been $725K/year. Contact Andrea Welch, broker at
317.373.6178 or email awelch@mid-ampracticesales.com.
Visit online at www.mid-ampracticesales.com
PORTLAND, IN - Open 4 days per week. Collections $1 mil-
lion/year. Contact Andrea Welch, broker at 317.373.6178 or
email awelch@midampracticesales.com. Visit online at
www.mid-ampracticesales.com
SPACE AVAILABLE
Ideal office space sharing opportunity in Fishers, IN. Great
location. 10 equipped operatories, 5,000 sq ft. Current doctor
will continue treating patients, but wants to fill more operato-
ries! Please contact Dr. Green at
sgreen@teamgreendentistry.com for more information.
EQUIPMENT
Pro-Tech Vinyl Repair & Upholstery, onsite upholsters of
dental chairs, furniture or equipment. We clean stools,
chairs, lobby seats, etc. Call 317.757.8304 or visit us online
at www.pro-techupholstery.com.
39 WWW.INDENTAL.ORG
Dr. Chris S. Ha (IUSD 2012)
Dr. Olga Isyutina (IUSD 2012)
Dr. John P. Jansen (IUSD 2012)
Dr. Amanda F. Kot (IUSD 2012)
Dr. Christopher J. Kumfer (IUSD 2012)
Dr. Brian LaBlonde (IUSD 2012)
Dr. Katie R. McNutt (Arizona University 2010)
Dr. Jeffrey M. McQuinn (IUSD 2012)
Dr. Patrick Murray (IUSD 2012)
Dr. Mikel Newman (IUSD 2012)
Dr. Chad E. Sloan (IUSD 2012)
Dr. Katherine E. So (IUSD 2012)
Dr. Shellie A. Steffen (IUSD 2012)
Dr. Kira L. Stockton (IUSD 2010)
Dr. Marc Stojkovich (IUSD 2012)
Dr. Jiyun Thompson (IUSD 2012)
Dr. Jenna E. Voegele (University of Minnesota 2011)
Dr. Nathan Webster (IUSD 2012)
ISAAC KNAPP DISTRICT
Dr. Jonathan P. Coudron
(Virginia Commonwealth University 2009)
Dr. Paul Fisher (Ohio State University 2012)
Dr. Keith J. Harrison (IUSD 2012)
Dr. Joel Micah Johnson (Case Western University 2009)
Dr. MatthewS. Kolkman (IUSD 2012)
Dr. Connie S. Shim (IUSD 2012)
NORTHCENTRAL
Dr. Jennifer C. Sitjar (IUSD 2012)
NORTHWESTINDIANA
Dr. Kara E. Clark (IUSD 2012)
Dr. Mark Dankowski (University of Louisville 2006
INDEX TOADVERTISERS
Bowman Insurance & Benefit Service IBC
Data-Safe IT Services 30
Dental Care Alliance 36
IDA Insurance OBC
Paragon Dental Practice Transitions 37
PNC Financial 41
ProAssurance 39
ProSites 35
Sikich 38
Travelers Insurance (IDAIS) IFC
40
JIDA
FALL 2012 VOL. 91, NO. 3
Dental students will talk about how difficult a certain profes-
sor is. The degree of vulgarity used to describe the professor
denotes the degree of difficulty. Newer students will also won-
der if it is possible to be a dentist who specializes in buccal pit
restorations.
Young dentists banter about the complexities of running a
practice. Their patient load is more arduous, cases more
demanding, staff more obscure, suppliers more testing, hours
more strenuous, and equipment more problematic than yours.
And whatever should be done about Pat who wont wear the
color coordinated dental team uniform?
Established dentists talk about extremely (in their eyes, any-
way) unusual patient cases (real and imaginary) and try to work
into the chatter seemingly unscripted comments about exotic
vacation getaways. And when we got back from our hang-glid-
ing trip over active artic volcanoes, the first patient scheduled
was a triple-impacted fourth molar endo!
Dentists at or near retirement age will talk about days gone by.
If younger dentists talk about the same thing, it is branded as
daydreaming but with age it is dignified as reminiscing. Theres
the chair-side assistant who could always put the correct instru-
ment in your hand before you knew you needed it. And Wanda,
who could clean and set up a room faster than anyone but rarely
had matching socks. And a crown was only $65 (and no such
thing as dental insurance). And old Dr. Frank, who had a one-
room office with no running water over the liquor store and car-
ried a bucket of coal up the stairs each morning to heat the place.
And these newdentists, they are so young and so talented.
Long-time, retired dentists chitchat about two things:
When do they serve the pudding? and Are there any restrooms
in this place?
And senile dentists will actually put a blindfold on at a dental
gathering and listen to see if these things are true. And it took me
a half hour to get the stupid thing off after I tried walking down
the up escalator.
Editors Note: Upon this, Dr. Carrolls last Funny Thing column,
the IDA Editorial Board extends its gratitude to the author for
helping members not take ourselves too seriously. We salute Dr.
Carrolls continuing contributions to the betterment of organized
dentistry.
FUNNY THING
SOCIAL SKILLS
IN DENTISTRY
Randy J. Carroll, DDS
Some things may never change.
Practice management gurus of many types and ilk often
harp on listening skills as a way to improve patient relations.
We are advised to position ourselves at conversational distance
(whatever that is), maintain eye contact (which eye, right or
left?), nod occasionally (with our eyes open and no snoring), and
intersperse the dialogue with, yes, I understand, and, thats
true (or similar meaningless utterances). While this has the
appearance of listening, actual hearing is not required.
Admittedly there are some instances where listening but not
hearing is a good thing. A recent patient, Mrs. McDonald (no
known relation to Ronald, but I wonder), was seated in the
exam room and was asked when her toothache started.
Well, she began, it was when my sister, the one who goes
to Florida for the winter, they have a real nice place there that is
just a few miles from the coast, she and her husband usually
head south when it gets cool, I think they drive down but they
do it in three days instead of two, because Edwin cant drive at
night ever since he started taking the medicine for his muscle
cramps or something, I forget exactly. They have a newcar that
Edwin got from his nephewwhen they were shipped overseas
thats blue, no gray, and it has plenty of room in the back for
their four dogs that are just like family, because if they ever
And ten minutes later you still dont know when the toothache
started. The whole exam takes twice as long as it should because
Mrs. McDonald talks at over 275 words per minute with gusts of
310. Your receptionist confirms that it took even longer just to
make the appointment due to excess verbiage. Its not that you
didnt use your listening skills; Mrs. McDonald obviously didnt
have anything to say.
On the other hand, some patients have more to say than they
in fact do say. Norton made repeated appointments to discuss a
proposed treatment. We listened. After the procedure he made
additional appointments to confer on follow up care. We patiently
welcomed his inquiries. Norton had recently lost his wife and
merely wanted to talk things over with someone who cared.
With time, one can sharpen ones listening skills to situations
beyond the operatory. If you would take me and put a blindfold
over my eyes and place me in a group of dentists, I would be able
to tell you how old they are just by listening to the conversation.
155th IDA Annual Session | May 16-18, 2013 | Hyatt Regency Indianapolis
This year, the IDA Council on Annual Session has planned
new and exciting activities to compliment our growing
sessions. Aside from our first-class breakout presenters,
were offering mini sessions with our new CE Express that includes
one-hour hot topic sessions.
New Exhibit Hall hours and events will be featured as well.
Were also pleased to welcome the Indiana University School
of Dentistrys Alumni Association to our Annual Session.
Image copyright 2012, Indianapolis Convention & Visitors Association; visitIndy.com
YOU WONT WANT
TO MISS OUT
ON THIS LINEUP!
DR. GORDON CHRISTENSEN
The Christensen Bottom Line 2013
DR. MARK HYMAN
Practice Management and Communications
DR. ROBERT EDWAB
Oral Surgery and Medical Emergencies Workshops
LACI PHILLIPS
Communications and Dental Insurance Strategies
/
The Indiana Dental Association is an ADA CERP recognized provider. ADA
CERP is a service of the American Dental Association to assist dental profes-
sionals in identifying quality providers of continuing dental education. ADA
CERP does not approve or endorse individual courses or instructors, nor
does it imply acceptance of credit hours by boards of dentistry.
Concerns or complaints about a CE provider may be directed to the provider
or to ADA CERP at ADA.org/goto/cerp.
DR. MITCHELL GARDINER
Dental Team and Malpractice Protection
DR. STEVE CARSTENSEN
Sleep Medicine, Bruxism, and Appliance Workshop
KAREN DAVIS
Treatment Planning and Oral Cancer Workshop
TIM CARUSO
Fitness, Back, and Neck Pain
DR. DON LEWIS
Embezzlement and Fraud
DR. TED PARKS
Oral Medicine Potpourri
and much more!
More than enough live CE credits to meet your licensure
requirements! For more information about our 2013
Annual Session, go online to www.INDental.org/Register.
Registration will open in October 2012!
Want to experience much more in Indy?
Visit www.visitindy.comto take a virtual tour of the city.
44
JIDA
FALL 2012 VOL. 91, NO. 3
in both print and on the website. Watch your mailboxes for
more information in the coming weeks. Please consider sup-
porting the IDA, while earning valuable continuing education.
As we carefully reshape the content, design, and distribution
methods for all IDA communications, we invite your honest
feedback. The hours and careful thought we devote to providing
valuable resources to members are not taken lightly, and we are
proud of what we deliver; however, we will only be effective
with your help, your insight, and your voice. Whatever your
age, whatever your communication preference, or whatever
your stance on any issue, this is your Association. Please reach
out to any of the Editorial Board members below to share how
you want IDA communications to be an asset to your practice
and career.
Jack Drone, DDSEditor
jwdrone@sbcglobal.net || 219.866.7117
Steven P. Ellinwood, DDSAssistant Editor
sedds85@aol.com || 260.492.2640
Michael D. Rader, DDSAssociate Editor
drrader@sbcglobal.net || 574.233.0014
William B. Risk, DDSPeer Review Editor
wriskdds@gmail.com || 765.742.0202
The Indiana Dental Association, since 1858, has
implemented a variety of communication tools to
reach and educate members about the develop-
ments in dentistry and the Association. Those at
the helm of informing members have faced their
own challenges in finding the most effective, creative ways to
both distribute and archive these communications and, as your
current Editor, I can say no different for this stage of our organi-
zations history.
Last spring the Editorial Board concluded that we must
be proactive in providing more valuable, useful content that
reaches the maximum number of members, while also shifting
our paradigm from one that accepts publications as a signifi-
cant financial loss to the IDA. How can we add to member
benefit, while helping the Association financially? We adopted
the following Mission Statement for publications, which will
nowappear at the front of every issue of the Journal:
Produce and distribute, at a profit, credible, high-quality
publications that inform Indiana dental practitioners about
the latest scientific, socioeconomic and political develop-
ments affecting dental practice and oral healthcare.
Our first major step in a new direction was the issue you are
holding in your hands (or reading on your iPad or computer
screen). Some of our most passionate, expert members and
friends of the Association discussed the topics and trends that
we must face as a professionand every outcome of each
emerging trend will impact every dentist. This is the type of
resource we want to put in your hands.
Your next issue, Sea of CE, will guide you through the pros
and cons of the various continuing education options bombard-
ing your mailbox on a daily basis. This spring, youll find the
latest tips for running the your practice, an ongoing struggle
for most practices. To round out this volume of the Journal, the
summer issue will be a crash course on revolutionary practice
management tools your entire dental team can use. These issues
are all still in the works, so let us know what youd like to see!
Perhaps most exciting for the Editorial Board is the addition
of continuing education to every issue, starting with the next
issue. Youll find a 1-credit self-study quizfree for members.
We are also developing Foundations, a 10-credit continuing
education resource featuring some of the biggest names and
hottest topics in dentistry. The new resource will be available
Something else is about to change
A New JIDA for the 21st Century Indiana Dentist
Jack Drone, DDS
Editor