Good and Bad about Mid-Level Providers

I read the white paper from the Academy of General Dentistry regarding mid-level dental providers (also known as dental health providers). And it solidified my position regarding the introduction of DHPs in Washington.

I still feel DHPs are a bad idea in most respects. But there are some advantages to DHPs too. And I wanted to express some positive views along with my choice to prohibit DHPs at this point.

The legislators who drafted this bill are barking up the right tree when it comes to improving access to dental care. Our residents need better access.

As the white paper states, dentistry's #1 job is to promote prevention of dental diseases. That job is effective when done properly. DHPs could do a huge service to the under-served by being dental health coordinators, who link prevention and screening, and refer patients to licensed dentists for intervention. Just getting patients in to a dental office is a huge step to educating, celebrating, and creating habits for great preventive behaviors in patients.

The word came down from The Washington State Dental Association that the bill for DHP is dead for now. Below is the memo:

February 13, 2012

BREAKING NEWS All Mid-Level Practitioner Bills are Dead for 2012 SB 6126 and HB 2226, the dental practitioner bills supported by the Kellogg Foundation and the Children’s Alliance, are now dead. HB 2226 died in the House Health Committee two weeks ago and SB 6126 will not pass out of the Senate Rules Committee. The WSDA appreciates our members' strong efforts and we're especially thankful for the leadership from the Board, committees, grassroots advocates and lobbyists. If you have received positive responses from your local legislators on WSDA’s position, please send them a thank you for supporting our concerns about patient safety and our continuing efforts to reduce barriers to oral health care. While these bills will not move any further this legislative session, support for a dental therapist model continues to grow among legislators and advocacy groups. Supporters of the legislation continue to amend introduced therapist bills and build support for the concept among other stakeholders. Put simply, this issue will not go away. We must continue to build our influence in Olympia. This year several dentists joined the grassroots advocacy program for the first time, but we still need more support from the dental profession. If you are not a member of the grassroots program, take a moment to join the campaign and be ready to work with your local legislators to protect patients and the profession. To sign up for the grassroots program, email michael@wsda.org . Thank you for your advocacy and continued action on behalf of the WSDA.

DHPs need to be put in place to help Washington patients. But there is more work to do in refining the definition of care they will provide.

Stay tuned--

My Girl Turned 2!

My daughter, Vivienne, turned 2 on the 6th. The reason this is so significant is that she has grown up a lot in the past 2 years, and is slowly overcoming a rare immune disorder. She has had a struggle with Food Protein Induced Entercolitis Syndrome. It results in a rejection of specific food proteins when they are ingested. It is different than an anyphylatic reaction, but equally as dangerous and requires hospitalization. This being the start of her third year of life, we have seen her outgrow the rejection of milk proteins. This is a huge step, but not the end of her troubles. Hopefully, doctors and researchers will progress in their understanding and treatment options for the disorder. Support is always needed. Check out the Kids with Food Allergies foundation, or go to their Facebook page.




Of course, I can't post about Viv unless we have some dental-worthy shots form her birthday celebration at preschool.

Senators Haugen and Shinn Hear From Me

SB 6126 is a bill proposed to institute dental health practitioners (DHPs) to alleviate the lack of Washington patients' access to dental care. DHPs are proposed to take over basic dental care under the supervision of licensed dentists. The bill suggests dentists and DHPs sign a "contract" that outlines how DHPs will discuss, plan, and execute treatment plans for patients under the direction of a dentist. The contract supposes that all medical and dental emergencies for the DHP patients will be mamanged according to this contract. And the contract must be upheld at any time, with the licensed dentist coming to the immediate aid of a DHP in the event a DHP has an issue, question, emergency, or a problem with a patient's care. I am really concerned that dentistry and state government are taking a wrong turn of this bill is passed. I am not worried about my own livelihood. I am worried about the reputation of dentistry and the endangerment of quality patient care.

Today, I wrote my senators Mary-Margaret Haugen and Paull Shinn.

"Senators,

You need to vote no for SB 6126.

The quality of Washington patients' dental care is currently suffering for many reasons. I have witnessed first hand the mass exodus of patients in my practice due to the recession we faced from 2008-2010. Most of those patients have not returned for care in any capacity. An estimated 40% of residents are without dental insurance, and choose to forgo regular, basic dental care. The Washington Dental Service fee reduction in 2011 has crippled many dentists' ability to offer quality dental care to those who still choose to pursue routine care. And a future fee reduction will hinder our Washington dentists' abilities to provide the best care possible to all types of patients. And with the introduction of SB 6126, the quality of care for patients is going to suffer even further.

As an expert in dentistry, I can admit to you that it has taken me well beyond my basic training to provide intelligent, comfortable successful therapy to patients, even for the most basic dental services. I do not feel that a dental health practitioner (DHP) will be able to deliver the standard of care that patients will expect. Patient access to care may be improved, but the DHP-delivered quality of care--specifically, the patients' judgement of the treatment results--will not be significantly improved.

You should be concerned about how a patient who travels to a DHP will decide to forgo dental care because of a negative experience. I am already privy to the experiences of patients who approach me with a sordid history of a licensed dentist's substandard ability to listen, interpret, and consult about their interests, and then deliver substandard restorative and prosthetic care--even the most basic of fillings. I have to hear about inadequate anesthesia, hurried and incomplete care, the list goes on.

You should be concerned that a DHP contract can accomplish fluid treatment with dentist oversight. There is no way that all aspects of a case can be controlled with a DHP contract. And trying to implement a phased plan of care for a patient with a DHP may be harder than introducing a DHP into an existing practice. Even a DHP with direct supervision will create a burden on the dentist for the DHP to deliver quality care. Doing it remotely will add more challenges to patient outcomes.

You should be concerned about the problems that will occur when A DHP gets into a situation where a licensed dentist has to stop their care for another patient, attempt to consult with the DHP via video feed to rectify a failed case without being present to correct or salvage it. Patients will turn sour. Patients will lose trust in dental care providers. And patients may suffer needless extra care visits. This amendment of SB 6126, above all others, is in my opinion, so beyond realistic expectations that I am worried about the reputation of dentistry in general.

There are too many variables beyond lawmakers' and dentists' controls if you elect to vote in favor of SB 6126. Do the dental industry and our patients the best possible of favors: vote no for SB 6126."

The bill is put before the legislature on 2/14/2012. I hope this bill fails. For everybody's sake.

Managing Apnea On The Road

A CPAP device is the standard for treating obstructive sleep apnea. The numbers of apneic patients is increasing annually. So there is a greater need to address their lifestyles and management of the disease at home an on the road. I thought it important to offer some tips and advice for managing apnea while traveling.

There are many CPAP and related devices on the market, but not all of them are travel-friendly. Recently, I got to try a System One device from Respironics, a Philips company. I was keen on the essential lack of noise from the machine, which has historically been the brunt of Darth Vader jokes. Being in a hotel room with this device wouldn't seem very distracting. Not only was it much quieter than models from even 5 years ago, it is also reasonably sized. Both the positive-pressure CPU and the mask fit into a laptop-sized carrying case.

Even though it's easy to put in your carry-on, I wouldn't recommend if you're hoping for a hassle-free airport screening. Stowing it in your luggage is probably your best choice. But if you're hell-bent on making your travels free of baggage, check this link from the TSA. It might be best to slip a copy of your treating physician's letter of medical necessity in the carrying case, in case the TSA decide you don't have a compliant appliance for travel. You can get one from your doctor upon request.

If you suffer from simple snoring all the way up up to moderate obstructive sleep apnea, and you and your spouse rely on a CPAP device for your health and sanity, you might want to consider an oral appliance. Most of them are acrylic with few metal parts, most are FDA approved, and usually don't require a letter from your doctor. The most popular device in recent years is the Thornton Adjustable Positioner, also known as the TAP appliance. It's the most compact way to manage your breathing obstruction.

We are experts at oral appliance therapy. Dr Rafoth is a member of the American Academy of Dental Sleep Medicine, and works intimately with sleep physicians in Snohomish County.
For more information, contact us today.