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The prosthodontist, the patient, and the public
RESEARCH AND EDUCATION SECTION
EDITOR
JOHN J. SHARRY
The prosthodontist,
the patient, and the public
Eric Bishop, M.S. * Chicago, Ill.
1 t is the quintessential Frenchman who, with a wary shrug and a Gauloises dangling from the corner of his mouth, sighs that the more things change, the more they are the same. Like most Gallic philosophy, that is partly true. Certainly, we are spared the Black Plague, unlike our fourteenth century brethren. They, on the other hand, did not have to watch the Gong Show. Certainly, we have managed, in most societies today, to devise some level beneath which human beings will not sink into misery. The Irish serf, on the other hand, didn’t have to deal with such modern “triumphs” as bombs that will disintegrate tens of thousands of us in one mushroom-shaped puff. On the whole, probably, the “good old days” were not really all that great. With Edmund Wilson, most of us would not trade our modern bathroom for 10 Chartres cathedrals. Despite the differences from century to century, however, we remain brothers and sisters who have much in common. One such common attribute, I suspect, is the conviction in any place at any time that what we are living through is more nerve shredding, more chaotic, more puzzling than any other people have ever had to face. We rather like to tell our miseries much the way my grandfather used to tell his beads on the back porch of a summer evening, with a rosary in one hand and a glass of undiluted whiskey in the other. Dentists, being human, so far as that can be measured, are as prone to dwell upon their wounds as are lawyers, steamfitters, or baseball players . . . well, perhaps not baseball players; their capacity to luxuriate in anguish while collecting salaries that on an annualized average exceed
Read before the Academy Fla. *Central Office Director, tions.
0022-3913/81/020205
of Denture
Prosthetics,
Federation
of Prosthodontic
+ 04$00.40/O
D 1981 The
Daytona
C. V. Mosby
Beach,
Organiza-
Co
$200,000 per year is unequalled except by the greed-laced folks who own the ball clubs. To be fair, dentists have much to complain about. It would not be purposeful here to detail the wellknown stories of large-scale indifference to oral health by too many people; the wrong-headed inaction of the Federal government with respect to dental care for the poor and the young; the arrogant interference, to some extent, of the Federal Trade Commission and the Government Accounting Office with matters that they do not bother to understand before changing; or the silly, but intensely frustrating, suspicion of fluoridation that lingers in so many parts of the nation. On the other hand -and there always is one- I am more inclined to take the view that dentists, dentistry, and dental health are more lively and better off than we might sometimes think as we ponder the half-empty glass, not noticing that it is also half full. I would suggest, as a dental witness once did before a Congressional committee, that while we are not perfect, we are quite perfectible. I would further suggest that there are steps, well within our capacity, which we can take to move us measurably forward in improving dental health as well as dentistry. I would suggest that most of these steps can be accomplished within the existing system, which is more enduring, and which better serves the millions of nondentists, than some commentators are prepared to admit. Finally, I would suggest that prosthodontics can and should play a major role in these various endeavors. Before going on to a series of semi-gratuitous suggestions, let me just briefly defend my central thesis - that we are not doing so badly after all. I would start, as does the total sequence of dental matters, with education. The educational system in the United States has few parallels, if any, elsewhere in the world and, certainly, none in past history. The
THE
JOURNAL
OF PROSTHETIC
DENTISTRY
205
blend of scientific orientation, clinical training, and research application is light-years ahead of where it would be were the profession less scrupulous or conscientious. Everyone - and I would be among the first - can think of improvements or refining calibrations. Nonetheless, we do have superb facilities available for teaching the art and science of dentistry. There is also a set of safeguards, the first steps in quality assurance, built into the system. The cynic will say that these safeguards are there to protect the turf; the idealist will say that they are there to protect the patient. Even if the cynic is right, the final effect serves to include protection of the patient, whether we are talking about predental aptitude tests, admission examinations, licensing, or relicensing. For example, it can be absolutely guaranteed when one is choosing a dentist in a new town that any man or woman using the title “dentist” has had to fulfill a considerable number of requirements and jump a considerable number of hurdles. If, after that, it is still cavaet emptor. we are still well ahcad as consumers. If I do want to visit a dentist, chances are that I will be able to find one geographically near where I live or work. While geographic access is not yet complete - indeed, this is one fault of the system - the most recent Federal figures, which identify some 18 million people living in dental shortage areas, indicate that more than 90% of the population has no difficulty with geographic access. We are batting 900, a better percentage than Babe Ruth ever did. People do, of course, visit dentists in considerable numbers. The most recent statistics indicate more than 100 million patients per year. This figure indicates more than 350 million visits per year, more than 1 billion services provided, and more than 12 billion dollars paid for those services. Every working day of the year, more than 1.3 million visits are made, and more than 50 million dollars are paid for services rendered. One net effect of this, of course, is that dentists are among the most highly compensated of any category of people in our society, with average net income now exceeding $40,000 per year. That, of course, makes dentists happy. On the whole, however, the most recent evidence seems to show that the patients are equally happy. In 1978, the American Dental Association (ADA) did a public opinion survey for the first time in a
206
number of years. By and large, the rc.sulls art’ 1~~11: interesting and gratifying. l:or csarnplt~. --48’%,of patients clainled to ha1.c. ‘iI1 their natl11 .ti teeth. --85’7 of patients said thcv knew they should go IO the dentist at lcast once ;I year (though onI!- SOIIIC’ 5X had actually done so in rhc. prrvious i .I months). -nearly 7.5? of the patients Ht’llt IO a cicntisl practicing alone. and more than !U’~; \ven~ IO .I dentist in the traditional private 1)ractic.c’. -more than 70% of the patients said they had IO wait onlv a few days to 2 weeks for :j nonemcrgenc\ appointment that was the first in a series and. once* in the of&e. 7 out of 10 had to wait less than Ii minutes for the visit to h+n. ---some 26’C of the patients said they had SOII~C~ type of insurancr coverage that hclprd pay the* dental bill; 7.5’;; said that dental prcpaymcnt c~vcrage extended to thr rntirc. farnil!-. not just {hf. particular worker. -among the ways patients decided whethcar thc.1, liked their present dentist (most people gave morc~ than one measurcl, some b:) ‘-“i said thcv liked their dentist because he talked about what \vas wrong and explained thr treatment procedure. Oflicc: cleanliness was mentioned by 1+3’:;: friendliness of personnc-I by 28’:; : discussion of fees bv 28’;;. ;\s to whether 111~ f‘ees were reasonable 1 2-l’:; of the patients felt thar they were. 1 think it is both significant and gratifying that the largest percentage of those surveyed conc‘(‘ntrated on the !rentrwnt aspects of care rather than th(, jinantlul aspects in making their judgment. -85% of the patients said they would recommend their prcscant dentist to ;I friend. with 55’;; saying thev would do so enthusiasticallv. Only 3%, said thra\ would not recommend their present dentist. --33’S of thr patients said they had, at one time or another. been dissatisfied Lvith a dental visit. CM those. 56’:; said they simply thought they had no1 received proper care: 24’Z thought the treatment used \vas too painful; and 1.5’;; thought the treat merit was too cxpcnsive. Ten percent thought that the dentist had been unfriendly or too curt. --about 30’;; of the patients said that dentists discussed fers before treatment. and some 23’S said that their dentist did not discuss fees prior I!) treatment. Nearly 5O’Y of those surveyed did not know whether or not the dentist had discussed fees prior to treatment, which must say something about the verbal skills of manv dentists.
I EBRUARY
1981
VOWME
55
NUMBER
2
PROSTHODONTIST,
PATIENT,
AND
PUBLIC
-some 70% of the patients said that they had never been prevented from receiving needed treatment because of the expense, and more than 90% said they had never experienced geographic access problems. -91% of the patients said that basic dental care was a necessary service and that it should be provided to people even if they cannot afford it. -if dentistry were to be included within national health insurance, more than 40% of those surveyed said they would want it to be provided through private offices. That is not a “report card” to be scorned. While our patients do not think we are perfect, the statistics would seem to indicate that they do see us as perfectible. One of the more interesting aspects of the survey, if I am interpreting it correctly, is the discrepancy between those questions that rely on personal experience for an answer and those questions which are more theoretic. The percentage of positive response is almost always higher when the question summons up personal experience than when it asks a theoretic one. That is part of the “my dentist is really fine but I have heard some funny stories about the other guys” syndrome. I suspect that the individual, doctor-to-patient relationship is, in fact, very important. All of these factors, of course, impress themselves on the dentist practicing prosthodontics just as they do for any dentist. However, there are two additional factors that, in my opinion, weigh heavier in prosthodontic practice. Unlike other aspects of dental care, there is a product involved in prosthodontics, in some cases, a removable prosthesis, I use the term product with care. I know that a service is a service. I know that what seems to be a mere product is, in fact, something infinitely more complicated. I also know, however, that there are sufficient characteristics so like those of a product that the general public is hopelessly confused when we attempt to make a major issue out of what seems, to them, to be a minor distinction. The point of concentration, I think, should not be on the terms used but on the person providing the service. A second complication for those engaged in prosthodontic care is the general thrust of dentistry toward preventive care which, at the far edge, makes tooth loss seem to be an ultimate failure of the person and the system itself. The overall movement in favor
THE JOURNAL
OF PROSTHETIC
DENTISTRY
of prevention is one that, I should think, can only be praised and supported. At the same time, there is nothing more contrary than human nature. With the lives we lead, for a whole range of invariable reasons, many of us are going to lose teeth. I myself lost my two front teeth, as one example of human vagaries, by thinking that I was a boxer and getting into a ring with someone who actually was a boxer. It was a short bout, just long enough for me to leave two front teeth on the canvas as I was propelled through the ropes. If the Lord can call upon us to forgive the sinner though he falls seven times seven, I assume we can include a little tooth loss within the foregiveness category. Perhaps a third factor should also be mentioned, the fact that there is a relatively small number of dentists engaged in strictly prosthodontic practice. In my opinion, those three points can be viewed as the major differentiations between those in prosthodontic practice, even if the practice is not wholly limited to that, and those in other fields within the profession. In that respect, I believe the prosthodontic community is sensible in directing much of its effort toward the activities of the profession at large, which is to say to the ADA. The ADA is the central organization and clearinghouse for American dentistry; by directing efforts of influence toward it, the possibility for achieving discernible goals is greatly enhanced. At the same time, of course, the prosthodontic community itself must have a fairly clear notion of just what it wants and a fairly unified stance in working toward the achievement of these aims. This seems to me to be a somewhat more complicated process within the prosthodontic community than it is for comparable areas of dental practice, education, or research. The existence of some 20 national organizations with defined interests in prosthodontics, loosely bound together into the Federation of Prosthodontic Organizations (FPO), presents some complications. It is through work for the Federation during these past 18 months that I have been primarily educated into the issues that exist. Obviously, my association with the Federation has influenced my viewpoint. I might say initially that I am convinced that if the Federation did not exist, it would have to be invented. A congress of that sort is essential within the prosthodontic community to deal with the massive national organizations such as the ADA. While
207
N
f
EDITOR
JOHN J. SHARRY
The prosthodontist,
the patient, and the public
Eric Bishop, M.S. * Chicago, Ill.
1 t is the quintessential Frenchman who, with a wary shrug and a Gauloises dangling from the corner of his mouth, sighs that the more things change, the more they are the same. Like most Gallic philosophy, that is partly true. Certainly, we are spared the Black Plague, unlike our fourteenth century brethren. They, on the other hand, did not have to watch the Gong Show. Certainly, we have managed, in most societies today, to devise some level beneath which human beings will not sink into misery. The Irish serf, on the other hand, didn’t have to deal with such modern “triumphs” as bombs that will disintegrate tens of thousands of us in one mushroom-shaped puff. On the whole, probably, the “good old days” were not really all that great. With Edmund Wilson, most of us would not trade our modern bathroom for 10 Chartres cathedrals. Despite the differences from century to century, however, we remain brothers and sisters who have much in common. One such common attribute, I suspect, is the conviction in any place at any time that what we are living through is more nerve shredding, more chaotic, more puzzling than any other people have ever had to face. We rather like to tell our miseries much the way my grandfather used to tell his beads on the back porch of a summer evening, with a rosary in one hand and a glass of undiluted whiskey in the other. Dentists, being human, so far as that can be measured, are as prone to dwell upon their wounds as are lawyers, steamfitters, or baseball players . . . well, perhaps not baseball players; their capacity to luxuriate in anguish while collecting salaries that on an annualized average exceed
Read before the Academy Fla. *Central Office Director, tions.
0022-3913/81/020205
of Denture
Prosthetics,
Federation
of Prosthodontic
+ 04$00.40/O
D 1981 The
Daytona
C. V. Mosby
Beach,
Organiza-
Co
$200,000 per year is unequalled except by the greed-laced folks who own the ball clubs. To be fair, dentists have much to complain about. It would not be purposeful here to detail the wellknown stories of large-scale indifference to oral health by too many people; the wrong-headed inaction of the Federal government with respect to dental care for the poor and the young; the arrogant interference, to some extent, of the Federal Trade Commission and the Government Accounting Office with matters that they do not bother to understand before changing; or the silly, but intensely frustrating, suspicion of fluoridation that lingers in so many parts of the nation. On the other hand -and there always is one- I am more inclined to take the view that dentists, dentistry, and dental health are more lively and better off than we might sometimes think as we ponder the half-empty glass, not noticing that it is also half full. I would suggest, as a dental witness once did before a Congressional committee, that while we are not perfect, we are quite perfectible. I would further suggest that there are steps, well within our capacity, which we can take to move us measurably forward in improving dental health as well as dentistry. I would suggest that most of these steps can be accomplished within the existing system, which is more enduring, and which better serves the millions of nondentists, than some commentators are prepared to admit. Finally, I would suggest that prosthodontics can and should play a major role in these various endeavors. Before going on to a series of semi-gratuitous suggestions, let me just briefly defend my central thesis - that we are not doing so badly after all. I would start, as does the total sequence of dental matters, with education. The educational system in the United States has few parallels, if any, elsewhere in the world and, certainly, none in past history. The
THE
JOURNAL
OF PROSTHETIC
DENTISTRY
205
blend of scientific orientation, clinical training, and research application is light-years ahead of where it would be were the profession less scrupulous or conscientious. Everyone - and I would be among the first - can think of improvements or refining calibrations. Nonetheless, we do have superb facilities available for teaching the art and science of dentistry. There is also a set of safeguards, the first steps in quality assurance, built into the system. The cynic will say that these safeguards are there to protect the turf; the idealist will say that they are there to protect the patient. Even if the cynic is right, the final effect serves to include protection of the patient, whether we are talking about predental aptitude tests, admission examinations, licensing, or relicensing. For example, it can be absolutely guaranteed when one is choosing a dentist in a new town that any man or woman using the title “dentist” has had to fulfill a considerable number of requirements and jump a considerable number of hurdles. If, after that, it is still cavaet emptor. we are still well ahcad as consumers. If I do want to visit a dentist, chances are that I will be able to find one geographically near where I live or work. While geographic access is not yet complete - indeed, this is one fault of the system - the most recent Federal figures, which identify some 18 million people living in dental shortage areas, indicate that more than 90% of the population has no difficulty with geographic access. We are batting 900, a better percentage than Babe Ruth ever did. People do, of course, visit dentists in considerable numbers. The most recent statistics indicate more than 100 million patients per year. This figure indicates more than 350 million visits per year, more than 1 billion services provided, and more than 12 billion dollars paid for those services. Every working day of the year, more than 1.3 million visits are made, and more than 50 million dollars are paid for services rendered. One net effect of this, of course, is that dentists are among the most highly compensated of any category of people in our society, with average net income now exceeding $40,000 per year. That, of course, makes dentists happy. On the whole, however, the most recent evidence seems to show that the patients are equally happy. In 1978, the American Dental Association (ADA) did a public opinion survey for the first time in a
206
number of years. By and large, the rc.sulls art’ 1~~11: interesting and gratifying. l:or csarnplt~. --48’%,of patients clainled to ha1.c. ‘iI1 their natl11 .ti teeth. --85’7 of patients said thcv knew they should go IO the dentist at lcast once ;I year (though onI!- SOIIIC’ 5X had actually done so in rhc. prrvious i .I months). -nearly 7.5? of the patients Ht’llt IO a cicntisl practicing alone. and more than !U’~; \ven~ IO .I dentist in the traditional private 1)ractic.c’. -more than 70% of the patients said they had IO wait onlv a few days to 2 weeks for :j nonemcrgenc\ appointment that was the first in a series and. once* in the of&e. 7 out of 10 had to wait less than Ii minutes for the visit to h+n. ---some 26’C of the patients said they had SOII~C~ type of insurancr coverage that hclprd pay the* dental bill; 7.5’;; said that dental prcpaymcnt c~vcrage extended to thr rntirc. farnil!-. not just {hf. particular worker. -among the ways patients decided whethcar thc.1, liked their present dentist (most people gave morc~ than one measurcl, some b:) ‘-“i said thcv liked their dentist because he talked about what \vas wrong and explained thr treatment procedure. Oflicc: cleanliness was mentioned by 1+3’:;: friendliness of personnc-I by 28’:; : discussion of fees bv 28’;;. ;\s to whether 111~ f‘ees were reasonable 1 2-l’:; of the patients felt thar they were. 1 think it is both significant and gratifying that the largest percentage of those surveyed conc‘(‘ntrated on the !rentrwnt aspects of care rather than th(, jinantlul aspects in making their judgment. -85% of the patients said they would recommend their prcscant dentist to ;I friend. with 55’;; saying thev would do so enthusiasticallv. Only 3%, said thra\ would not recommend their present dentist. --33’S of thr patients said they had, at one time or another. been dissatisfied Lvith a dental visit. CM those. 56’:; said they simply thought they had no1 received proper care: 24’Z thought the treatment used \vas too painful; and 1.5’;; thought the treat merit was too cxpcnsive. Ten percent thought that the dentist had been unfriendly or too curt. --about 30’;; of the patients said that dentists discussed fers before treatment. and some 23’S said that their dentist did not discuss fees prior I!) treatment. Nearly 5O’Y of those surveyed did not know whether or not the dentist had discussed fees prior to treatment, which must say something about the verbal skills of manv dentists.
I EBRUARY
1981
VOWME
55
NUMBER
2
PROSTHODONTIST,
PATIENT,
AND
PUBLIC
-some 70% of the patients said that they had never been prevented from receiving needed treatment because of the expense, and more than 90% said they had never experienced geographic access problems. -91% of the patients said that basic dental care was a necessary service and that it should be provided to people even if they cannot afford it. -if dentistry were to be included within national health insurance, more than 40% of those surveyed said they would want it to be provided through private offices. That is not a “report card” to be scorned. While our patients do not think we are perfect, the statistics would seem to indicate that they do see us as perfectible. One of the more interesting aspects of the survey, if I am interpreting it correctly, is the discrepancy between those questions that rely on personal experience for an answer and those questions which are more theoretic. The percentage of positive response is almost always higher when the question summons up personal experience than when it asks a theoretic one. That is part of the “my dentist is really fine but I have heard some funny stories about the other guys” syndrome. I suspect that the individual, doctor-to-patient relationship is, in fact, very important. All of these factors, of course, impress themselves on the dentist practicing prosthodontics just as they do for any dentist. However, there are two additional factors that, in my opinion, weigh heavier in prosthodontic practice. Unlike other aspects of dental care, there is a product involved in prosthodontics, in some cases, a removable prosthesis, I use the term product with care. I know that a service is a service. I know that what seems to be a mere product is, in fact, something infinitely more complicated. I also know, however, that there are sufficient characteristics so like those of a product that the general public is hopelessly confused when we attempt to make a major issue out of what seems, to them, to be a minor distinction. The point of concentration, I think, should not be on the terms used but on the person providing the service. A second complication for those engaged in prosthodontic care is the general thrust of dentistry toward preventive care which, at the far edge, makes tooth loss seem to be an ultimate failure of the person and the system itself. The overall movement in favor
THE JOURNAL
OF PROSTHETIC
DENTISTRY
of prevention is one that, I should think, can only be praised and supported. At the same time, there is nothing more contrary than human nature. With the lives we lead, for a whole range of invariable reasons, many of us are going to lose teeth. I myself lost my two front teeth, as one example of human vagaries, by thinking that I was a boxer and getting into a ring with someone who actually was a boxer. It was a short bout, just long enough for me to leave two front teeth on the canvas as I was propelled through the ropes. If the Lord can call upon us to forgive the sinner though he falls seven times seven, I assume we can include a little tooth loss within the foregiveness category. Perhaps a third factor should also be mentioned, the fact that there is a relatively small number of dentists engaged in strictly prosthodontic practice. In my opinion, those three points can be viewed as the major differentiations between those in prosthodontic practice, even if the practice is not wholly limited to that, and those in other fields within the profession. In that respect, I believe the prosthodontic community is sensible in directing much of its effort toward the activities of the profession at large, which is to say to the ADA. The ADA is the central organization and clearinghouse for American dentistry; by directing efforts of influence toward it, the possibility for achieving discernible goals is greatly enhanced. At the same time, of course, the prosthodontic community itself must have a fairly clear notion of just what it wants and a fairly unified stance in working toward the achievement of these aims. This seems to me to be a somewhat more complicated process within the prosthodontic community than it is for comparable areas of dental practice, education, or research. The existence of some 20 national organizations with defined interests in prosthodontics, loosely bound together into the Federation of Prosthodontic Organizations (FPO), presents some complications. It is through work for the Federation during these past 18 months that I have been primarily educated into the issues that exist. Obviously, my association with the Federation has influenced my viewpoint. I might say initially that I am convinced that if the Federation did not exist, it would have to be invented. A congress of that sort is essential within the prosthodontic community to deal with the massive national organizations such as the ADA. While
207
N
f