By Michael W. Davis, DDS | February 17, 2014
Dr. Mark Malterud has been practicing Minimally Invasive Restorative Dentistry for over 30 years in St Paul Minnesota. He has had the opportunity to help many patients achieve excellent oral health. His passion for Dentistry has led him into involvement into Organized Dentistry where he has been Minnesota’s President of the Academy of General Dentistry and has chaired at the National level, the AGD’s Council on Dental Education and is the current Region-10 AGD Board of Trustees member. He helped get the Academy of Biomimetic Dentistry up and running and sits on the Board of the World Congress of Minimally Invasive Dentistry. As a consummate student and innovator in Dentistry he has been invited and presented lectures around North America and the World. Mark@drmalterud.com
Dr. Davis: Dr. Malterud, I’m honored to bring forth this interview. You’ve done a great deal facilitating education for the dental profession, which eventually serves the public interest. Services dentistry can provide patients today is greatly advanced, from 10-20 years ago. You have personally contributed to this wonderful progress, some of which I hope to expand upon with our discussion.
Dr. Davis: The dental profession today is exposed to newer concepts, such as “minimally invasive dentistry”. Over time, these principles are becoming accepted into dental university curriculums and the general practice of dentistry. Please explain to the average person, what is meant by minimally invasive dentistry and how it may benefit them. Please give a few specific examples, in our rethinking of traditional treatment protocols.
Dr. Malterud: I appreciate being asked to be interviewed for this column. As far as the meaning of Minimally Invasive Dentistry (MID), I can sum it up fairly easily. It is a philosophy that tooth structure is sacred and once removed it cannot be brought back. So, treat every lesion and problem from the perspective that we remove the problem (pathology) and restore it as definitively as we can with modern technology.
The reality is that whatever we place in the mouth to restore what has been lost will break down, and, in time, given enough use, will fail. However, technology, materials and techniques are constantly being developed, and, when the time comes for restorations to be replaced, we will have better materials to restore the tooth. I heard it once described as tooth banking by Dr. Ray Bertolotti and that is a good description.
Frankly it is a lot easier and sadly more profitable to prepare a tooth for a crown than it is for a dentist to remove the pathology,bond back the portions that have been destroyed and leave a lot of solid tooth structure to work with in the future. It’s nice to know that a few schools are embracing this philosophy now and hopefully it will spread to more. It’s just doing what is best in the long-term for the tooth and ultimately the patient.
Dr. Davis: I know you practice dentistry St. Paul, Minnesota. Both Minnesota and Alaska currently have active dental therapist programs, which serve Native American populations. Personally, I have mixed feelings about dental therapist programs, because of potential for abuse, if expanded into the realm of interstate corporate dentistry, where oversight has often been negligent. However, I respect the sovereignty of native nations, and their right of self-determination. How has the dental therapist program worked in Minnesota? Do you have any concerns?
Dr. Malterud: Minnesota’s Dental Therapist Programs are up and running and, frankly, they weren’t put into effect to treat the Native American populations. It was created to serve perceived underserved populations. However, out of the total of 27 dental therapists (DT) and advanced dental therapists (ADT) who have graduate in Minnesota thus far, only 22 are believed to be practicing, and, of these folks, only 6 are known to be practicing in community health settings. Minnesota law requires the Minnesota Dental Board to produce a program evaluation report of the DT and ADT programs this year, but regardless of what comes out, DTs and ADTs are not currently providing enough care in the field to produce any valid results as to patient health outcomes.
On the other hand, the Academy of General Dentistry spent a lot of time creating a white paper on Access and Utilization of Care, followed by a white paper explaining Barriers and Solutions to Accessing Care. These papers provide a lot of proven strategies on how to address what is really an under-utilization of dental services due to a lack of emphasis on oral health literacy, and a maldistribution of dentists available to treat these underserved populations, in part due to underfunding the need for service in poor and rural areas.
Frankly if I am going to seek out care, I want a fully trained dentist who, if presented with an interprocedural complication, can take the situation to its ultimate appropriate treatment outcome, rather than a paraprofessional having to stop and call in the dentist to remedy the situation.
Corporate Dentistry is ripe to hire these midlevel providers as some may perceive them as cheap labor, but, if they want them to drill and fill under the corporate structure, they are opening up a potential can of worms. Those who hire midlevel providers such as dental therapists will have to be sure that they stay within the scope of practice and don’t overstep their bounds when they get into trouble with an interprocedural complication. Often times, the population that is intended to be served by these paraprofessionals is a more at-risk population that really should have a well-trained dentist to sleuth out any possible complications such as complex medical histories and previous adverse outcomes. Without a well trained dentist’s diagnosis and planning, these patients actually may be more at risk. .
Organized Dentistry has solutions but there are forces out there driving this whole movement that is detrimental to patients and, frankly, I don’t understand it. We have adequate capacity of work hours to treat all of these populations and with a good dental team, many more patients can be treated but nobody will fund this care adequately. The problem that we have is that we keep being thrust into a medical model that has failed miserably and we get compared to MD’s and nurse practitioners, but we are a different breed. In my eyes, we are really the only healthcare out there that works . We begin with prevention and early treatments. Until medicine takes on a more preventive route, we are going to be controlled by the need for a disease diagnosis before providers can be paid. It’s much cheaper to prevent disease than to treat disease further down the road when they become emergencies.
Dr. Davis: I want to change the subject a bit, and delve into what some consider the mundane topic of taxes. Both your state of Minnesota and my state of New Mexico charge a tax fee on dental healthcare services. The Minnesota Care Provider Tax is currently 2%. The New Mexico gross receipts tax ranges, depending on county and city, from approximately 7 to 9%. Certainly states have the right of taxation, to fund a variety of public services. However, I find taxation of dental services, to be overly burdensome and regressive to many least able to afford this needed healthcare (working poor, elders on fixed incomes, etc.). On one hand, government says it wants to expand access to dental care, yet invokes tax policies which promote the opposite. I’d appreciate your comments.
Dr. Malterud: This is certainly an issue that you and I are very familiar with and I have the same feelings towards how inequitable it is. In Minnesota, it was set up originally as a way to fund more public service healthcare and to date, we in dentistry have seen so little of the 100’s of millions collected over the years go back into treating dental patients. Over the past years, this 2% fund has been raided time and again to balance the budget in Minnesota and so it was transferred into the General Tax funds to take care of revenue shortfalls. The sad truth is that, with these funds being transferred, those in need are not getting the care that they should be getting. Until our legislators realize that dental health leads to overall systemic health, they will keep up with their 3 Card Monty game that keeps the public in the dark. Then groups turn around and say that dentists aren’t compassionate and are just money hungry. Something to think about for the general public out there is that if it costs 65 or 70 cents on a dollar to just keep a dental office up and running, how can a program like Minnesota's Minncare program pay 35 cents on the dollar for reimbursements of very limited procedures and still have the dentist pays a 2% provider tax on that. If a grocery store had to sell their groceries to Food stamp recipients for 35 cents out of every dollar that they charge for their food, you can sure bet that the Program would collapse immediately or all grocery stores would go out of business.
Dr. Davis: When government policy promotes an uneven playing field between small business and big business, and picks “winners and losers”, we call that crony capitalism. Small business dentistry generally has a dentist/owner, who resides in that state and community. They spend money, by purchase of goods and services within that state and community. Their business profits generally stay in that state, and are taxed as earned income or in-state corporate profits. By contrast, big business interstate corporate dentistry generally reassigns profits, to “overhead operating expenses” for accounting purposes, and removes that income generally to accounts in Delaware, to avoid state tax consequences. Would you care to comment on this form of crony capitalism, and how it may negatively impact the future dental care for our citizens, as well our communities generally?
Dr. Malterud: When you bring in big business into dentistry, specifically if you have shareholders who do not have a personal interest in the clinical decisions, the idea becomes to have some economy of scale so that they can increase the corporate profits to their shareholders. Dentists generally aren’t overly interested in handling the business aspect of their practices; so when someone comes in and dangles a carrot in front of them that looks like it will relieve them of some of those burdens and gives them an exit strategy, they think that they can just do what they love to do and help their patients and this all seems great. Once you take a bite of that carrot you realize that some of the liberties that they had as a solo practitioner or a partner in the old practice are lost, such as they often can’t use their favorite restorative materials or labs because the corporation has a deal with a manufacturer or lab to supply them with a product that is less expensive. When corporations start to dictate procedures and sales techniques, all in the name of corporate profits, ultimately the patient loses. One of the biggest reasons I practice dentistry is because of the relationships that develop with patients and the ability to help people become healthier. When the bottom line becomes the driver, the patient loses. The writing is on the wall that some forms of corporate dentistry will affect all of us eventually, but there are those of us out there that will continue to advocate to make sure that we maintain the quality of relationships and the care that our patients deserve, regardless of the model of practice. Patients are not numbers; they are living breathing human beings who deserve to be able to choose what is best for them.
Dr. Davis: I was very pleased to read the response by the Academy of General Dentistry (AGD), to the bipartisan US Senate Committee Report on Corporate Dentistry, of July 2013.
While some within organized dentistry seemed to waffle in support of this important document, the AGD took an unequivocal firm stand, in support of the public interest. W. Carter Brown, DMD, FAGD, Academy of General Dentistry president-elect and chair of the AGD Corporate Dentistry Task Force stated, “The report is not a broad-brush discussion of all of the corporate models. Rather, it offers an in-depth analysis that states may use to determine when business models, actions, or contractual agreements of dental management companies may not be providing the appropriate level of treatment planning, care, and oversight.” The “broad brush” referencing was specific, to refute the American Dental Association’s (ADA) comments, which seemingly gave a pass to pervasive abuses observed in corporate dentistry. Could you discuss further on the AGD’s Corporate Dentistry Task Force, and how their work serves the public welfare?
Dr. Malterud: I am very proud of the work of the task force. Dr. Brown’s task force did an exemplary job in coming up with a whole series of questions that dentists should ask before signing on the bottom line with any practice model, including becoming a provider for a corporate dental program or to sell their practice to a corporate entity. However, I believe the “broad brush” reference was not intended to refute the ADA. Instead, I believe the report is “not a broad-brush discussion,” because the truth that there are numerous variations in corporate practice, and, if you’ve seen one model, you’ve seen just one model. I know that there are some very good Corporations out there so I don’t want to denigrate all of them but there are also some instances where my felow colleagues end up with seller’s remorse as they realize that they have lost the ability to practice the type of Dentistry that kept them excited. Drilling, filling and billing for dental procedures becomes expected when you are directed to keep your production numbers up more than to pay attention to the relationships to provide the patients with exemplary care.
Dr. Davis: A number of organized dentistry groups have established a “Patient Bill of Rights”, which they openly post on their organization’s websites. I’m particularly impressed with the Patient Bill of Rights established by the Minnesota Dental Association. This document is easy to read and understand, for the average dental patient. It isn’t crafted in difficult legal terms, which discourages readers. It says to me, very loud and clear, we dentists care about your well-being. You have important rights, and we’d love to be of service, to you and your family. Could you please add your perspectives, Dr. Malterud?
Dr. Malterud: I think that the task force that put that together did a great job and reflects exactly what a patient’s rights and responsibilities are. The sad part is that, with the encroachment of contractual dentistry such as employer-provided closed panel reimbursement plans, the ability to choose your dentist isn’t as easy as it used to be. You may have to go to one of the plan “preferred providers” or face the reality that you are paying for your dental care outside of your employer’s plan. From my own perspective as a solo practicing dentist who runs a basic fee-for-service practice, I choose not to sign onto any of the insurance programs because giving a break to patients insured by one company places the burden of keeping my office up and running on those patients or payers that pay full fee for service. Not only this but if a service isn’t covered by an insurance plan, then the doctor and patient may elect a less-ideal service that will be covered by the patient’s plan. Now, who is deciding on the patients treatment? The patients bill of rights really is important to the patients’ ability to get the care that they need or desire, but, as we have been discussing, there are frequently outside forces that complicate the process.
Dr. Davis: Dr. Malterud, I’d like to thank you for this highly informative interview, on a wide variety of important subjects. I appreciate doctors like yourself, who not only provide outstanding care for your patients locally, but also involve yourself in advancement of our dental profession, and service to the public’s benefit.