Monday, May 06, 2013

Interview of American Academy of Pediatric Dentistry President, Dr. Joel Berg by Dr. Michael W. Davis

Bios of Dr. Joel Berg and Dr. Michael Davis.

Dr. Joel BergDr. Joel Berg is current president of the American Academy of Pediatric Dentistry and named dean of the University of Washington’s School of Dentistry in 2012. He was previously an executive at Philips Oral Healthcare and 3M’s ESPE Dental. Dr. Berg is an inventor and has authored numerous articles and manuscripts. He is also co-editor of the textbook on early childhood oral health. His latest invention is the Pediatric Bur Block for DVI.

He is a fellow of the American College of Dentists and International College of Dentists, as well as a board director of the American Academy of Esthetic Dentistry. In 2011, he was named the Washington Dental Service Foundation Distinguished Professor for Dentistry.

Dr. Michael DavisDr. Michael W. Davis has achieved national recognition as an expert dental lecturer and author. His current private practice, SMILES OF SANTA FE, has successfully helped hundreds of patients achieve and maintain spectacular smiles and optimal oral health since 2003.  Dr. Davis holds membership in the Academy of General Dentistry, the American Dental Association, and the New Mexico Dental Association. His presentations include speaking for the American Academy of Cosmetic Dentistry, Association of Cosmetic Practices, Cruise and Learn Alaska Seminar, and the International AACD in San Antonio. As an author, Dr. Davis' articles have appeared in many respected publications, including Dental Economics, Dentistry Today, Journal of Cosmetic Dentistry, and Journal of the American Dental Association. He also serves on the editorial review board for the Journal of Cosmetic Dentistry.

Interview of American Academy of Pediatric Dentistry President, Dr. Joel Berg

Dr. Davis: We continue to see a disturbing degree of misrepresentations in dental marketing and advertising, in which general dentists attempt to represent themselves as specialists. Sometimes, this is seen with individual practitioners, and sometimes we see these misrepresentations from larger interstate dental providers. We can’t expect the public to have our degree of sophistication and professional knowledge, to read fact from fiction. How can the public best be protected from these unprofessional charlatans?

Dr. Berg: A big part of the answer is for state dental boards to enforce the laws and regulations that are currently on the books concerning the criteria for specialty advertising (namely, that a dentist cannot state or imply specialization absent appropriate training in one of the nine recognized dental specialties). The AAPD provides guidance on advertising to our affiliate (general dentist) members and we have also shared this with state dental boards. We applaud those general dentists who take care of children and do so in accordance with AAPD’s clinical guidelines. For purposes of advertising, the AAPD believes the following terms are acceptable by a general dentist: Family Dentistry, General Dentistry for Children or General Dentistry for Children and Families. However, the AAPD believes the following phrases are confusing to the public and contrary to the membership obligations of the Affiliate category: Child Dentistry, Children’s Dentistry, Dentistry for Children, Dentistry for Kids or Pediatric Dentistry. Affiliate members using such terms are subject to disciplinary action by the AAPD. We are aware that some corporate chains have names that are misleading, and we believe that state dental boards should appropriately regulate such advertising.

Dr. Davis: We have both personally witnessed some very exceptional recent graduates from our dental educational programs. These junior colleagues are bright, motivated, and offer our profession and the public a wonderful future. Unfortunately, too many of these recent grads are saddled with a highly burdensome student loan debt, often exceeding $200-300,000. Student loan debt is not dischargeable in a bankruptcy action.

In former years during a stronger economy, a senior dentist would routinely take on a junior colleague, as an associate dentist. The senior dentist could share the patient caseload, and enjoy some additional time off from the day-to-day responsibilities of clinical and business practice. The junior dentist was afforded a learning experience with positive income. He or she could be mentored, during a formative period in their developing career.

Today, things have changed. Many of those former associateship positions are gone. Public health dentistry may or may not pay adequately, to meet student debt obligations. Student loan forgiveness for practicing in underserved communities may only generate a pitiful sum. Certain business-first types in dentistry seem to take advantage. I am concerned these facilities, commonly called “dental mills”, which neglect to place patients’ interests at the fore, prey upon our vulnerable recent graduates. What can organized dentistry do, to assist these fine younger doctors?

Dr. Berg: The topic of student indebtedness is under constant discussion. The amount of indebtedness varies greatly between public and private dental schools. The American Dental Education Association (ADEA) collects and publishes data from graduates including data about educational debt. The most recent survey was conducted for 2011 dental school graduates. The amount of debt varies greatly between public and private dental schools. ADEA reported that the average graduating educational debt of those from public dental schools was just under $178,000 and for private schools, it was under $245,000. What’s important to note in these figures is that the stated amounts are inclusive of all educational debt; undergraduate and dental school. According to the ADEA survey, students entering dental school in 2007 had already incurred educational debt above $52,000. Subtracting out the entering debt significantly reduces dental school expenses.

There are some alternative means to relieving student debt. One method for debt reduction is for a recent graduate to become faculty at a dental school or graduate program. The AAPD has been successful in lobbying policymakers for Title VII grant funding for the Dental Faculty Loan Repayment Program. There are five dental schools and pediatric dentistry programs which are current recipients of funding under the Dental Faculty Loan Repayment Plan. These grants are awarded to dental schools or graduate programs to plan, develop and operate a dental faculty loan repayment program for faculty engaged in primary care dentistry which includes pediatric dentistry. Individuals participating in the program must agree to serve as full-time faculty members. The program must agree to pay the principal and interest on the outstanding student loans of the individuals. Upon completion by an individual of each of the first, second, third, fourth and fifth years of service, the program shall pay an amount equal to 10, 15, 20, 25 and 30 percent, respectively, of the individual’s student loan balance as calculated based on principal and interest owed at the initiation of the agreement.

Other federally funded programs include Grants to States to Support Oral Health Workforce Activities. These grants may also be targeted for loan forgiveness and repayment programs for dentists who agree to practice in designated dental health professional shortage areas (HPSAs). There is also the National Health Service Corps Loan Repayment Program which can pay up to $60,000 in loans for a service commitment.

Dr. Davis: The AAPD has been very proactive with the concept of a“dental home” for our nation’s children, regardless of social or financial status (insert web link). We have very positive volunteer outreach programs in dentistry, such as Mission of Mercy. Unfortunately, these intermittent volunteer programs fail to fully meet the criteria of dental home. Likewise, a mobile dental program, which visits a public school only for a couple of days on a yearly basis, also fails to meet the necessary criteria. We also have dental clinics run by certain corporate groups, which turn over associate doctors’ employment, often on a 4-6 monthly basis, virtually guaranteeing patients will not see the same doctor, often more than once.

Dr. Berg, please explain the concept of dental home, and what suggestions do you have to ensure a dental home for all our nation’s children?

Dr. Berg: A Dental Home, is an ongoing relationship between the patient and the dentist or dental team that is coordinated/supervised by a dentist;

  • provides comprehensive, coordinated, oral health care that is continuously accessible and family-centered; and
  • · is an approach to assuring that all children have access to preventative and restorative oral health care.

The benefit of dental services delivered within the context of a Dental Home is highlighted by Paul Casamassimo and Art Nowak (2002), “Children who have a Dental Home are more likely to receive appropriate preventive and routine oral health care. This provides time-critical opportunities to implement preventive health practices and reduce the child’s risk of preventable dental/oral disease.”[i]

Early engagement in a Dental Home can also significantly reduce the cost of care. In fact, engagement in a Dental Home by the age of one year improves the likelihood that a child will receive more preventive services and require less treatment than those children who accessed dental services at an older age.[ii]

Interaction with early intervention programs, schools, early childhood education and child care programs, members of the medical and dental communities, and other public and private community agencies will ensure awareness of age-specific oral health issues.[1]Community organizations can be great advocates of good oral health practices, including entry into a dental home: the individuals in these organizations can meet families “where they are”, so to speak, in moving them forward in an understanding of the importance of oral health to physical, developmental and emotional wellbeing and encouraging utilization of dental services already available in the community.

Pediatric dental practices are the backbone of the oral health care for our nation’s children. On average, 70% of pediatric dentists participate in Medicaid or CHIP, comprising on average 25% of their patients. Improvement in Medicaid reimbursement rates and a reduction of the administrative burden of participating in Medicaid would enable even more providers, including general dentists, to participate in Medicaid and CHIP.

When it comes to achieving good oral health, many low-income and minority children face significant challenges. These factors include both internal family factors such as parental belief systems and health practices, as well as external factors, such as availability of providers and transportation. In order to effectively engage families in a dental home, one must look to solutions that improve both access and utilization by assisting families in overcoming these barriers.

Title VII Pediatric Dentistry funding addresses the shortage of pediatric dentists (Title VII refers to health professions training funds). Increased # of pediatric dentists has made a difference in access over the past 15 years. And we anticipate this trend to continue along with continued level title VII funding.

Dr. Davis: The AAPD’s position paper on patient rights and responsibilities is a very timely and important document (insert web link). Of current interest is the informed consent process, which should be a guarantee, for every dental patient. At the AAPD grassroots level is pediatric dental specialist, Dr. Lee Weinstein (Scottsdale, AZ), who is working with the Arizona Dental Association to formulate state laws, to protect the public, and ensure patient rights of the informed consent process. We’ve seen the unfortunate consequences for patients, of for-profit mobile dental services within public schools, utilizing blanket waivers, in the place of the informed consent process.

I’d appreciate reading your thoughts on the importance, of the work of grassroots AAPD Membership like Dr. Weinstein. Please also comment on this vital position paper formulated by the AAPD, and its value to the public.

Dr. Berg: This document: (

is clear that a good patient/family and dentist relationship requires good communication and collaboration. We intentionally said rights AND responsibilities. The AAPD understands that proper informed consent is a process, not just a piece of paper. Given challenges in oral health literacy, especially among lower income families, it is all the more important that treatment options are clearly explained and understood. This includes the consequences of non-treatment. The AAPD also strongly support establishment of a Dental Home for every child, starting with the age one visit. We support any dentist, dental clinic, or even mobile facility that provides a true Dental Home consistent with AAPD clinical guidelines. In contrast, we believe that “skimming” or screen and clean operations are not a good use of public or private resources and not in the best interests of the child.

Many pediatric dentists play vital roles in advocacy for children at the federal, state and local levels. Advocacy is part of the new pediatric dentistry residency training accreditation standards. The AAPD has supported the training of our members via legislative workshops, public policy conferences in Washington, D.C., and leadership institute training at two of the nation’s top business schools (Kellogg at Northwestern University and Wharton at the University of Pennsylvania). In 2012, we initiated a state Public Policy Advocates program, appointing one point person in each state to coordinate advocacy efforts for our state chapters—in close coordination with state dental associations and the AAPD.

Dr. Davis: We in the dental professional, as well as the general public, have been made acutely aware by the media, US Department of Justice, numbers of states’ attorney generals offices, and the Office of Inspector General of the Department of Health and Human Services, of disturbing actions of abuse inflicted against disadvantaged children and fraud perpetrated upon taxpayers, by numbers of corporate interstate Medicaid dental service organizations (DSOs). In large part, these clinics are controlled by various investment banking firms. We’ve both discussed these activities with former staff (doctors and auxiliaries), which previously worked in these environments, as well as patients and their parents. I have personally audited billing statements from some of these DSOs, only to discover a pattern of rampant Medicaid fraud.

Several former officers of the AAPD chose to affiliate themselves, their reputations, and possibly the reputation of the AAPD, with numbers of these large interstate Medicaid dental providers (usually in an advisory capacity). You have elected to avoid even the appearance of ethical compromise, and not attached your name to one of these DSOs. You have my respect and gratitude for this.

Please comment on the importance of the AAPD’s position, in respect to serving the dental profession, pediatric dental specialists, and most importantly the public interest. How important is it for AAPD leadership, to maintain ethical standing?

Dr. Berg:  The AAPD supports any dentist or dental clinic caring for children consistent with our clinical guidelines. While I cannot comment on any pending investigations by the government, in one recent settlement of a Medicaid fraud case the corporate entity had to invest in greater continuing education for their staff, including a better understanding of AAPD clinical guidelines. Some pediatric dentists have become involved with entities focused on Medicaid populations because of the dentist’s genuine and humane concern to help under-privileged children received oral health care. I cannot speak for every situation and every individual. If a pediatric dentist is helping to improve the quality of care in dental clinics consistent with AAPD clinical guidelines, that is a good thing. If any dentist is involved in an organization that he or she believes is delivering sub-standard care, he or she has an ethical obligation to remedy the situation in some manner.

[1] American Academy of Pediatric Dentistry. Policy on the dental home. Reference Manual 2007-2008; 29(7): 22-23.

[i] Nowak, AJ & Casamassimo, PS. The dental home: A primary care oral health concept. Journal of the American Dental Assoc, 2002; 133(1): 93-98.

[ii][ii] Savage, M, Lee, J, Kotch, J and Van, W. Early preventive dental visits: effects on subsequent utilization

and costs. Pediatrics 2004;114;418-423.

DTM  would like to thank Dr. Berg for granting this interview with Dr. Davis.  DTM would love to hear your thoughts. Please comment below.