- Email: [email protected]
Quality assurance for 21 years
Le t t e r s to E dito r
the
Dr. F e in m a n ’s letter brin g s up m any g o o d p o in ts . C o s m e tic d e n tis tr y has opened new horizons in dental care and w hen ap p ro ach ed w ith the balance Dr. F ein m an describes, is an indispensable p a r t of a m o d e rn p ractice. I ce rtain ly agree that it can be unethical to not offer needed and desired services to patients. Dr. B u c h a n a n ’s le tte r, on the o th e r h a n d , is a n a tte m p t to lo o k at ju stic e issues from a p a rtic u la r political view p o in t he espouses. If he really believes we are free a n d th e re fo re have no o b lig a tio n to an yone b u t ourselves, he n eed s to ta k e th e tim e to e x p lo re h is o w n th in k in g an d m aybe a tte n d som e courses in ethics and philosophy. . . . J O H N A. G IL B E R T , DMD, MLA U N IV E R SIT Y O F M ISSOURIKANSAS C ITY
Quality assurance for 21 years □ I c o m p lim e n t y ou o n th e ex c ellen t se lf-e v a lu a tio n /s e lf-a s s e s s m e n t/q u a lity assu ra n ce a rticle s in the J u ly issue of T h e Jo u rn a l. I do n o t find th a t credit has been given to the dentist and dental organization for creating such a program 21 years ago. In 1967, Frank M. McCarthy, MD, DDS, spoke to the S outhern C ali fornia Society of O ral and M axillofacial Surgeons (SCSOMS) on anesthesia and m e d ic a l e m e rg e n c y in -o ffic e q u a lity assu ran ce. A v o lu n ta ry se lf-e v alu a tio n program was recom m ended an d adopted in Ja n u ary 1968.1,2 In a d d itio n to Dr. M cC arth y , o th e r m em bers of the SCSOM S, Drs. A drian H u bbell, L eland Reeve, H ow ard Davis, an d th e late J o h n H a g a n were in s tru m e n ta l in im p le m e n tin g th e selfevaluation program . T h is in-office audit becam e a m e m b e rsh ip re q u ire m e n t in 1970, a n d is rep e ate d every 5 years to m a in tain m em bership. As far as I know, th is is th e firs t e x a m p le of r e q u ir e d c o n tin u in g office au d it in the US health p ro fe s sio n s. In 1974, S C SO M S ad d e d the phrase “ self-regulation in the public interest” to its official logo. Several years later the A m erican Asso ciatio n of O ra l a n d M axillofacial S u r geons (AAOMS) ad o p ted the SCSOM S 10 ■ JADA, Vol. 118, January 1989
office audit on a n atio n al basis, and the o peratio n s m an u al was u p d ated by Dr. M cCarthy. State boards of dental exam iners later used the SCSOM S p ro g ra m as a basis of in-office ex a m in a tio n for g en e ral an e sth e sia lic en su re , a n d c u r rently, ap p ro x im ately 80% of the states have the requirem ent of c o n tin u in g office a u d it to su p p ly g en eral an esth esia. At least tw o fo reig n h e a lth o rg a n iz a tio n s are o ffe rin g in-office a n e s th e s ia /e m e r g en cy se lf-a sse ssm e n t o n a v o lu n ta r y basis, the Society for the A dvancem ent of A naesthesia in D entistry (G reat B ritain) an d th e S ociety fo r th e A d v an c em e n t of Analgesia and A naesthesia in D entistry (Australia). TH O M A S H . B IR N EY , DDS PR E S ID E N T S O U T H E R N C A L IF O R N IA SO C IE TY O F O R A L AND M A X ILLO FA C IA L SU R G E O N S 1. M c C a rth y FM . A n e sth e s ia -e m e rg e n c y selfe v alu atio n m anual. Los A ngeles, S ou th ern C alifornia Society of O ral and M axillofacial Surgeons, 1968. 2. M cC arthy FM. Prevention of em ergencies and m a lp ra c tic e c la im s by in -o ffic e p e e r re v ie w . In: M id d le to n RA , ed. C u rre n t th e ra p y in d e n tis try , vol 7. St. Louis: CV M osby, 1980.
Performance time and gloves □ T h e article, “ G loved an d ungloved: perform ance tim e for tw o dental proce dures” by Dr. H ardison an d others (May), in d ic a te d th a t g lo v in g a n d re m o v in g gloves increased tim e for each procedure by a n a v e rag e o f o n ly 28.7 se co n d s. A c c o rd in g to T a b le 1, th e p ro c e d u re percentage tim e, how ever, increased by 30%. If th is h eld tru e th r o u g h o u t th e dental office procedures, then either the provider m ust raise fees 30% or p roduction w ill be 30% less. . . . It w ould be interesting to see this research carried o ut on a m ore com pre hensive basis: for exam ple, the difference in the average tim e of procedures d u rin g an entire week. W ILLIA M H . O L IV E R , DMD N A SH V IL LE, T N
TMJ testing □ In recent years, the dental profession in g e n e ra l a n d th e A m e ric a n D e n ta l A sso c ia tio n in p a r tic u la r h av e been d eluged w ith p ro d u cts c la im in g to be “ d ia g n o stic in stru m e n ts ” for te m p o ro m andibular (TM ) disorders. T h e a p p a ll ing lack of adequate scientific research has lead to sk e p tic ism , cy n icism , a n d a large credibility g ap in this field.
. . . In re sp o n s e to th e 1982 ADA president’s conference on T M disorders, I in it ia t e d a n d d ire c te d an o n g o in g re se a rc h p r o g ra m a t P a in R e so u rc e C enter, D u rh am , N C, to learn ho w to d ev elo p an a c c u ra te a n d re lia b le p sy ch o m etric assessm ent to o l for T M d is orders. “ Psychom etric testing” is a phrase th at the dental profession w ill be hearin g m o re in th e n e a r fu tu re . In g e n e ra l, psychom etric testin g refers to the m ea surem ent of m ental traits, abilities, an d processes. In practice, it has evolved in to a scien tific d isc ip lin e often focused on assessment of clinical param eters th ro u g h se lf-re p o rt sy m p to m in v e n to rie s. P sy chom etric testing has a 100-year history in the field of psychology and in recent years has made a significant co n trib u tio n to th e m ed ical p ro fessio n . T h e d e n ta l p ro fessio n has n o t yet felt th e im p a c t of this pow erful form of clinical assess ment. . . . T h e stra te g y w e u sed w as to a d o p t w ell-a cc ep te d th e o rie s a n d te c h n iq u e s of test d ev e lo p m e n t used in th e fields of psychology and behavioral an d social sciences an d rig o ro u s ly ap p ly th em to th e p ro b le m s of T M d iso rd e rs. We u n d e rto o k a m u ltis ta g e a n d m u ltis ite 5-year research program w hich involved the co llaboration of 30 clinicians in 19 states and C anada, studying alm ost 3,000 subjects. T h e re su ltin g assessm ent tool w as c a lle d th e T M J S cale a n d it is b e g in n in g to g a in m o re w id e s p re a d ac c e p ta n c e a fte r b e in g em p lo y ed su c cessfully by d en tists across th e US on thousands of patients. T h is w ill require the establishm ent of technical standards for test dev elo p m en t as well as ethical standards and guidelines for use of such tests. . . . W hen the dentist is confronted w ith e v a lu a tin g an y p sy c h o m etric tests, the follow ing questions should be asked: 1. Was test developm ent accom plished in ap p ro p riate dental p atien t p o p u la tio n s an d tested o n large en o u g h samples? 2. Was test construction based on wellac c e p te d a n d v a lid a te d th e o rie s a n d techniques? 3. H ave ad equate statistical a n d clin ical studies of the various types of validity (accuracy) an d reliability (consistency) been conducted? 4. H as the test been cro ss-v alid ated , th at is, tested o n large num bers of p atients in diverse se ttin g s w h o w ere n o t p a r t of the o rig in al test developm ent study? 5. H as the test’s accuracy been m easured a g a in s t a su ita b le " g o ld s ta n d a r d ” or external criterion?
the
Dr. F e in m a n ’s letter brin g s up m any g o o d p o in ts . C o s m e tic d e n tis tr y has opened new horizons in dental care and w hen ap p ro ach ed w ith the balance Dr. F ein m an describes, is an indispensable p a r t of a m o d e rn p ractice. I ce rtain ly agree that it can be unethical to not offer needed and desired services to patients. Dr. B u c h a n a n ’s le tte r, on the o th e r h a n d , is a n a tte m p t to lo o k at ju stic e issues from a p a rtic u la r political view p o in t he espouses. If he really believes we are free a n d th e re fo re have no o b lig a tio n to an yone b u t ourselves, he n eed s to ta k e th e tim e to e x p lo re h is o w n th in k in g an d m aybe a tte n d som e courses in ethics and philosophy. . . . J O H N A. G IL B E R T , DMD, MLA U N IV E R SIT Y O F M ISSOURIKANSAS C ITY
Quality assurance for 21 years □ I c o m p lim e n t y ou o n th e ex c ellen t se lf-e v a lu a tio n /s e lf-a s s e s s m e n t/q u a lity assu ra n ce a rticle s in the J u ly issue of T h e Jo u rn a l. I do n o t find th a t credit has been given to the dentist and dental organization for creating such a program 21 years ago. In 1967, Frank M. McCarthy, MD, DDS, spoke to the S outhern C ali fornia Society of O ral and M axillofacial Surgeons (SCSOMS) on anesthesia and m e d ic a l e m e rg e n c y in -o ffic e q u a lity assu ran ce. A v o lu n ta ry se lf-e v alu a tio n program was recom m ended an d adopted in Ja n u ary 1968.1,2 In a d d itio n to Dr. M cC arth y , o th e r m em bers of the SCSOM S, Drs. A drian H u bbell, L eland Reeve, H ow ard Davis, an d th e late J o h n H a g a n were in s tru m e n ta l in im p le m e n tin g th e selfevaluation program . T h is in-office audit becam e a m e m b e rsh ip re q u ire m e n t in 1970, a n d is rep e ate d every 5 years to m a in tain m em bership. As far as I know, th is is th e firs t e x a m p le of r e q u ir e d c o n tin u in g office au d it in the US health p ro fe s sio n s. In 1974, S C SO M S ad d e d the phrase “ self-regulation in the public interest” to its official logo. Several years later the A m erican Asso ciatio n of O ra l a n d M axillofacial S u r geons (AAOMS) ad o p ted the SCSOM S 10 ■ JADA, Vol. 118, January 1989
office audit on a n atio n al basis, and the o peratio n s m an u al was u p d ated by Dr. M cCarthy. State boards of dental exam iners later used the SCSOM S p ro g ra m as a basis of in-office ex a m in a tio n for g en e ral an e sth e sia lic en su re , a n d c u r rently, ap p ro x im ately 80% of the states have the requirem ent of c o n tin u in g office a u d it to su p p ly g en eral an esth esia. At least tw o fo reig n h e a lth o rg a n iz a tio n s are o ffe rin g in-office a n e s th e s ia /e m e r g en cy se lf-a sse ssm e n t o n a v o lu n ta r y basis, the Society for the A dvancem ent of A naesthesia in D entistry (G reat B ritain) an d th e S ociety fo r th e A d v an c em e n t of Analgesia and A naesthesia in D entistry (Australia). TH O M A S H . B IR N EY , DDS PR E S ID E N T S O U T H E R N C A L IF O R N IA SO C IE TY O F O R A L AND M A X ILLO FA C IA L SU R G E O N S 1. M c C a rth y FM . A n e sth e s ia -e m e rg e n c y selfe v alu atio n m anual. Los A ngeles, S ou th ern C alifornia Society of O ral and M axillofacial Surgeons, 1968. 2. M cC arthy FM. Prevention of em ergencies and m a lp ra c tic e c la im s by in -o ffic e p e e r re v ie w . In: M id d le to n RA , ed. C u rre n t th e ra p y in d e n tis try , vol 7. St. Louis: CV M osby, 1980.
Performance time and gloves □ T h e article, “ G loved an d ungloved: perform ance tim e for tw o dental proce dures” by Dr. H ardison an d others (May), in d ic a te d th a t g lo v in g a n d re m o v in g gloves increased tim e for each procedure by a n a v e rag e o f o n ly 28.7 se co n d s. A c c o rd in g to T a b le 1, th e p ro c e d u re percentage tim e, how ever, increased by 30%. If th is h eld tru e th r o u g h o u t th e dental office procedures, then either the provider m ust raise fees 30% or p roduction w ill be 30% less. . . . It w ould be interesting to see this research carried o ut on a m ore com pre hensive basis: for exam ple, the difference in the average tim e of procedures d u rin g an entire week. W ILLIA M H . O L IV E R , DMD N A SH V IL LE, T N
TMJ testing □ In recent years, the dental profession in g e n e ra l a n d th e A m e ric a n D e n ta l A sso c ia tio n in p a r tic u la r h av e been d eluged w ith p ro d u cts c la im in g to be “ d ia g n o stic in stru m e n ts ” for te m p o ro m andibular (TM ) disorders. T h e a p p a ll ing lack of adequate scientific research has lead to sk e p tic ism , cy n icism , a n d a large credibility g ap in this field.
. . . In re sp o n s e to th e 1982 ADA president’s conference on T M disorders, I in it ia t e d a n d d ire c te d an o n g o in g re se a rc h p r o g ra m a t P a in R e so u rc e C enter, D u rh am , N C, to learn ho w to d ev elo p an a c c u ra te a n d re lia b le p sy ch o m etric assessm ent to o l for T M d is orders. “ Psychom etric testing” is a phrase th at the dental profession w ill be hearin g m o re in th e n e a r fu tu re . In g e n e ra l, psychom etric testin g refers to the m ea surem ent of m ental traits, abilities, an d processes. In practice, it has evolved in to a scien tific d isc ip lin e often focused on assessment of clinical param eters th ro u g h se lf-re p o rt sy m p to m in v e n to rie s. P sy chom etric testing has a 100-year history in the field of psychology and in recent years has made a significant co n trib u tio n to th e m ed ical p ro fessio n . T h e d e n ta l p ro fessio n has n o t yet felt th e im p a c t of this pow erful form of clinical assess ment. . . . T h e stra te g y w e u sed w as to a d o p t w ell-a cc ep te d th e o rie s a n d te c h n iq u e s of test d ev e lo p m e n t used in th e fields of psychology and behavioral an d social sciences an d rig o ro u s ly ap p ly th em to th e p ro b le m s of T M d iso rd e rs. We u n d e rto o k a m u ltis ta g e a n d m u ltis ite 5-year research program w hich involved the co llaboration of 30 clinicians in 19 states and C anada, studying alm ost 3,000 subjects. T h e re su ltin g assessm ent tool w as c a lle d th e T M J S cale a n d it is b e g in n in g to g a in m o re w id e s p re a d ac c e p ta n c e a fte r b e in g em p lo y ed su c cessfully by d en tists across th e US on thousands of patients. T h is w ill require the establishm ent of technical standards for test dev elo p m en t as well as ethical standards and guidelines for use of such tests. . . . W hen the dentist is confronted w ith e v a lu a tin g an y p sy c h o m etric tests, the follow ing questions should be asked: 1. Was test developm ent accom plished in ap p ro p riate dental p atien t p o p u la tio n s an d tested o n large en o u g h samples? 2. Was test construction based on wellac c e p te d a n d v a lid a te d th e o rie s a n d techniques? 3. H ave ad equate statistical a n d clin ical studies of the various types of validity (accuracy) an d reliability (consistency) been conducted? 4. H as the test been cro ss-v alid ated , th at is, tested o n large num bers of p atients in diverse se ttin g s w h o w ere n o t p a r t of the o rig in al test developm ent study? 5. H as the test’s accuracy been m easured a g a in s t a su ita b le " g o ld s ta n d a r d ” or external criterion?