NDA JOURNAL Fall 24 Volume 26, Issue 3 Official Magazine of the Nevada Dental Association and Component Societies A Peer Reviewed Journal
FALL 24 NDA JOURNAL Editor’s Message Daniel L. Orr II, DDS, MS (anesth), PhD, JD, MD 2 Featured Articles Electronic Medical Records, An Information Bubble?: EMR Claims vs. Reality 4 EHR Copy-and-Paste Can Get Physicians Into Trouble 8 In the Tiger’s Mouth: A History of Veterinary Medicine, Part 1 of 4 11 ALEC Model Policy on Dental Therapy; ADA Commentary 14 Fluoride Toxicology; ADA Talking Points 18 Trust me... It's good for you 19 Reports NDA President Patrick Silvaroli , DMD 22 NDA Executive Director Marianna Kacyra 24 NNDS President K.C. Gilbert, DMD, MS 25 SNDS President Christine Lemon, DDS 26 SNDS Executive Director Esther Johnson 27 NNDS Executive Director Lori Benvin 28 NDF President David Mahon, DDS 30 Sections Event Calendars 33 Administrative Offices & NDA Committees 34 On the Cover U.S. Navy Dental School, Washington, D.C. (1931) Nevada Dental Association 600 E. William Street, Ste 202 Carson City, NV 89701 PH 775-558-9404 FAX 702-255-3302 EMAIL [email protected] WEB www.nvda.org NDA Journal is published four times each year by the Nevada Dental Association and state component societies. All views expressed herein are published on the authority of the writer under whose name they appear and are not to be regarded as views of the publishers. We reserve the right to reduce, revise, or reject any manuscript submitted for publication. Materials: All articles, letters to the editor, photos, etc. should be sent to Daniel L. Orr II, DDS, via email to [email protected]. All chapter and committee reports and business communications should be sent to Marianna Kacyra, Executive Director, Nevada Dental Association, 600 E. William Street, #202, Carson City, NV 89701. Ph: 775-558-9404. Materials may be reproduced with written permission. Subscription: Members receive each publication as a membership benefit paid by membership dues. Non-members may subscribe to the Nevada Dental Association Journal for $50 annually. Advertising Policy: All advertising appearing in the NDA Journal and other Nevada dental publications must comply with the advertising standards of the Nevada Dental Association and its component societies. The publication of an advertisement is not to be construed as an endorsement or approval by the publishers of the product or service being offered in the advertisement unless the advertisement specifically includes an authorized statement that such approval or endorsement has been granted. The publishers further reserve the right to cancel any and all contractual advertising agreements should an advertiser be engaged in litigation concerning their product or service, or should the product or service be in conflict with the standards of the NDA or its component societies. Advertising rates and specifications are available upon request. Contact, William Hutabarat, Big Red M, at 571-331-3361 or email [email protected]. Mailing: Send address changes to: 600 E. William Street, #202, Carson City, NV 89701. © 2024 Nevada Dental Association Editor Daniel L. Orr II, DDS, MS (anesth), PhD, JD, MD [email protected] Publisher Big Red M www.bigredm.com Design: Shelby Bigelow NDA JOURNAL
NDA Journal 2 Dr. Orr practices Anesthesiology and OMS in Las Vegas, is an Adjunct Professor (Surgery) at UNLV SM and Touro University SM (Jurisprudence), Professor Emeritus at UNLV SDM, and a member of the CA Bar and Ninth Circuit Court of Appeals. Editor’s Message Daniel L. Orr II, DDS, MS (anesth), PhD, JD, MD [email protected] NDAJ Exclusive EHR 101 Someone, sans ID, walked into a Las Vegas hospital charting area this week and walked out with four hospital computers. Reportedly, the culprit was asked who he was and what he was doing. The ID-less perpetrator offered that he was from Information Technology (IT) and was directed to retrieve four computers. He was allowed to do just that; so much for protected information security. The feckless employees will now attend a retraining session about the loss of at least tens of thousands of protected records. Now, if someone walked into a dental office, picked up some computers with protected information on them, and disappeared, guess who would be in trouble, to the tune of potentially hundreds of thousands of dollars in fines in addition to administrative, civil, and even criminal prosecution? Yes, the dentist with the license. A huge problem for doctors who use electronic health records (EHRs) is that they are generally the only ones held accountable for data breeches. National, state, and municipal governments, corporations and their employees, insurance companies, software manufacturers, and pretty much any other third-party that doesn’t have a health professional’s license generally is simply advised to be more careful.1 Nowadays, a significant consideration for such breeches is that records are often electronic. Thousands of patient files are much easier to steal if they’re digital as opposed to on paper. This is but one disadvantage of an EHR. Historically, many of us remember being taught how to develop a hard copy, handwritten document. What we actually wrote down is secondary to EHR issues discussed herein. What is important is the purpose of the record. Remember? The primary reason we created patient records was to optimize patient care. The records belonged to the doctor and were actually, as opposed to today, truly protected and confidential. Today, EHRs are neither protected nor confidential as seen with frequent huge data breeches of millions of citizens. And no individual is responsible for the breeches, except of course the gullible doctors. EHRs are kept for vastly different reasons than our paper records were. Those of us who are coerced to used EHRs by third-parties know the new priorities have little to do with optimizing patient care. When EHR advocates speak in public, for decades they aways tout the toogood-to-be-true evanescent benefits of efficiency and safety, which is never the reality of the EHR. What is true is that the primary purpose, as iterated more privately, is to facilitate coding, ideally by vulnerable doctors, for more efficient billing. And boy, do some billers bill. I accepted a case recently for which a third molar was removed from a veteran who had undergone significant head-and-neck cancer therapy. He had vascular clips throughout his neck, had undergone a laryngectomy, and the standard radiotherapy. The tooth was removed in the OR because of the co-morbidities, not the difficulty of the 1–2 minute odontectomy. The office fee for this procedure would have been exponentially less than hospital bill of more than $18,000. But, don’t worry, the vet didn’t have to pay for it—the taxpayers did. Another primary purpose of EHRs includes creating wealth for the conflicted software developers for endless programs that always, as in 100% of the time, do not perform as advertised. Often, EHRs also relieve third-party billing entities of the burden of retaining coders, as doctors are now assigned to code procedures. UNLV
Fall 24 www.nvda.org 3 Editor’s Message SDM invited Dr. Paul Bornstein, who wrote a book on coding, to get the faculty up to speed on correct coding. His talk included the opinion that all (100%, including himself) dentists have committed insurance fraud. That actually makes sense after the passage of Obamacare in 2010. Obama and the HHS adopted the unconstitutional burden of proof posture that accused doctor coders of being guilty until they can prove themselves innocent, just like the IRS does. The accusation often metastasizes to doctor bios and CVs (i.e., Have you been investigated in the last two years?— a common recredentialing query). Some states require that if one is accused, entities are required by law to report the alleged rascally health professionals to sister agencies. For instance, a civil court would be required to report the doctor to the AG for possible criminal prosecution and also to the State Board for an administrative evaluation. A current case in another state involves administrative allegations and proposed penalties directly stemming from an EHR. A civil suit soon followed. The dentist’s staff mistakenly checked an incorrect box on the EHR, for which the doctor is, of course, responsible. The doctor actually developed a contemporaneous paper record that is correct, but the state apparatchiks want to simply dismiss the correct document out-of-hand. One bit of good news for dentists is that our CDTs are composed of only about 650 codes, while our medical colleagues must dance with 140,000 plus. It’s almost as if someone wants our physician colleague to make coding errors—go figure. That brings us to other not responsible for anything beneficiaries of EHRs, both plaintiff and defense attorneys. Depending on the way things fall out, they either view EHRs as scripture or as misinformation emitted from a vomitorium. EHRs are not true scripture, ever. They are in fact massive laundry lists that doctors must sort correctly, or face the consequences. Laundry lists never work either.2,3 If one does a search for problems with EHRs, literally thousands of articles will be revealed. One thing all these submissions have in common is that the doctor whose name is on the EHR is virtually always the one left holding the bag, absent proven criminality of another. Some of the problems often listed are: 1.They Are a Waste of Valuable Time: Perhaps this is a blessing if one works in time frames, rather than with patients. It took a couple of hours to complete the EHR for the two minute surgery mentioned above. Those hours happily represent less time to spend on other EHRs, but sadly, also less time left for actual patients. 2.Data Entry (coding): See 1. in part. 3.Alerting is Absent: Incorrect, or ambiguous, as in obscure allergies. 4. Inoperability: Routinely. 5.Visual Display: Chaotic. 6.Availability of Information: In reality, there is too much useless information to sort through. The doctor may be held responsible for everything in the chart, even the data of others. 7.System Automation and Defaults: There are always glitches. 8.Improved Versions Never End and Always Contain New Errors. 9. Workflow Support: Hospitals have assigned charting rooms with EHR computer babysitters for doctors attempting to use EHRs-surgery is much more straightforward. 10.Patient Harm: Generally, directly related to the EHR chaos. So, what is a doctor to do? Well, it is difficult to refuse to use an EHR when one’s employer requires it. As a courtesy to Nevada Dental Association Journal (NDAJ) readers, the following statement is something I try to attach to each EHR I am compelled to interact with. This is not legal advice nor an NDA-sanctioned treatment plan by any means, just a thought to consider: “The Electronic Record Developed by Dr. __________ for __________ is an Accommodation Only. Attestation Of Dr. __________’s Electronic Record Accuracy Is Perfected Via Dr. __________’s Notarized Physical Signature Only. Dr. __________’s Authorized Patient Record Will Be Maintained By Dr. __________.” Of course, dentists who unilaterally choose to use this or that software can’t attempt to assign blame to another. Good Luck! 0 References 1. Acenas R, 2.9 Billion Records Stolen in Hack, Including Social Security Numbers, Lawsuit Alleges, Epoch Times U.S. News, https:// www.theepochtimes.com/us/2-9-billion-records-stolen-in-hackincluding-social-security-numbers-lawsuit-alleges-5706444?utm_ source=morningbriefnoe&src_src=morningbriefnoe&utm_ campaign=mb-2024-08-16&src_cmp=mb-2024-08-16&utm_ medium=email&est=AAAAAAAAAAAAAAAAZeMlfBYAh87a% 2FpMbsGlPRbF%2B3g8R%2F5hN4kB%2FtGCswZ88%2BZ8%3D, accessed August 15, 2024. 2. Ismail J. Letter to the Editor. NDAJ. 2011;13(1):11. 3. Orr D. Dentistry Is? … NDAJ. 2009;10(4):5–6. 4. Pew Foundation (as reported by the AMA), https://www.ama-assn.org/ practice-management/digital/7-ehr-usability-safety-challenges-and- how-overcome-them, accessed July 17, 2024. A huge problem for doctors who use electronic health records (EHRs) is that they are generally the only ones held accountable for data breeches.
NDA Journal 4 Featured Article Electronic Medical Records, An Information Bubble?: EMR Claims vs. Reality by: AAPS News, March 2013 We often hear about the phenomenal exponential growth of digital technology, with the implicit assumption that the doubling will continue—unlike exponential growth phases in nature, which are part of an S-shaped curve—and that it is an unmitigated blessing. The amount of paper in a print-out of a patient’s chart and the amount of data one is required to gather also keeps doubling. It reminds me of the 1797 poem Der Zauberlehrling by Johann Wolfgang von Goethe and the Disney animation (“The Sorcerer’s Apprentice” in Fantasia). The apprentice calls up spirits to animate a broom to carry water to fill his bath, but forgets the magic word to stop it. Hacking the broom in half just doubles the deluge: “Die ich rief, die Geister, werd’ ich nun nicht los!” [“The spirits I summoned will not let me go!”] Claims vs. Reality The electronic medical record (EMR) is touted as the key to containing costs, reducing errors, improving quality, and simplifying administration: an “elegant exercise in wishful thinking,” in the words of Jerome Groopman and Pamela Hartzband. The real motive appears to be control (AAPS News, April 2011). Indeed, to spur adoption, EMRs are becoming semi-compulsory. For example, the performancein-practice (PIP) component of the Federation of State Medical Board’s Maintenance of Licensure template is EMR-dependent Also, physicians who are not “compliant” with various electronic requirements will have their Medicare fees cut. The federal government has “invested” $20 billion over the last two years in promoting health information technology (HIT), based on expectations from a 2005 RAND study of $81 billion in annual savings. The study was paid for by a group of companies that profit from selling EMR systems to hospitals and physician practices. Cerner’s revenue nearly tripled since the report was released, from $1 billion in 2005 to a projected $3 billion in 2013. The RAND study deliberately avoided looking at negative information. Double-blind, randomized studies have shown that EMRs with computerized decision-making tools did not result in a single improvement in any quality measure in the care of chronic diseases, and has not been shown to save money, writes Greg Scandlen. Some think the growth of HIT is a bubble, which is very often the result of misallocation of funds derived from government subsidies (http://tinyurl.com/adwhj5r). Costs have clearly increased. As an article in the NY Times pointed out, hospitals that received government incentives to adopt EMRs had a 47% rise in Medicare costs, compared to 32% in hospitals that did not. Scot Silverstein, M.D., of Drexel University, describes the rapid changeover to EMR as a mania. “We know it causes harm, and we don’t even know the level of magnitude.” Poorly designed software can obscure clinical data and generate incorrect treatment orders. Errors voluntarily reported to the Food and Drug Administration (FDA) probably reflect a small percentage of events that actually occur. There is a tacit admission by experts that EMRs by themselves don’t improve quality of care. You have to have an army of technical consultants in your office, writes Lawrence Huntoon, M.D., Ph.D. One study reported that it took at least nine months of EMR use and eight or more technical assistance visits to show any statistically significant improvements in key quality measures. Even after two years, physician offices without such support showed no improvement (Health IT News 1/9/13). Bad Engineering In an article entitled “Escaping the EHR Trap,” Kenneth Mandl, M.D., M.P.H, and Isaac Kohane, M.D., » But what if the current HIT bubble bursts, and better HIT helps physicians and patients take back medicine?
NDA Journal 6 Ph.D., write that commercial electronic health records evolved from practicemanagement (i.e. billing) systems, with various modules tacked on. Physicians are locked into pre-internet systems that are not designed to link with third-party applications and do not even embrace existing modular architectures. Complex software that was never properly engineered “must be reimagined, reinvented, and reimplemented constantly.” Entrenched “legacy” approaches and other factors stifle innovation (NEJM 6/14/12). In the same issue, Spencer Jones et al. describe the “IT productivity paradox.” During the 1970s and 1980s, the computing capacity of the U.S. economy grew one hundredfold, while the rate of productivity growth fell to less than half that of the preceding 25 years. In the early 20th century, it took two decades to figure out how to realize the benefits of electricity, as factories initially replaced waterwheels and steam engines with large electric motors running the same central belt-and-pulley system. The breakthrough was to use small electric motors that provided power when and where it was needed. Individual autonomy, self-directed work teams, “home-grown” IT systems relying on user-centered design practices are suggested. Does this spell “fragmentation” and “decentralization,” instead of top-down central planning? The federal government may be using HIT to drive more standardization and tighter regulation and monitoring of physicians—with the sacrifice of professional autonomy and independent clinical judgment. But what if the current HIT bubble bursts, and better HIT helps physicians and patients take back medicine? HIT: The Bad and The Ugly Template Bloat: Pre-programmed template notes are a workaround for time-consuming data entry. Wordfor-word identical progress notes, even lengthy operative reports, are commonplace. The template includes what usually happens and what might happen, and notes may include pages of things that never happened (http://tinyurl.com/afgs23y). Virus-Infected Medical Devices: Software-controlled medical devices are increasingly interconnected and internet-linked. Many run on older operating systems that are vulnerable to hackers and cannot be changed, even to add antivirus software, because of fear of violating FDA rules. Malware is rampant in many hospitals, from drug compounders to image-archiving systems (http://tinyurl.com/d6jcx8j). 0 » Featured Article
NDA Journal 8 EHR Copy-and-Paste Can Get Physicians Into Trouble by: Leigh Page, Medscape, April 11, 2024 Physicians who misuse the “copyand-paste” feature in patients’ electronic health records (EHRs) can face serious consequences, including lost hospital privileges, fines, and malpractice lawsuits. In California, a locum tenens physician lost her hospital privileges after repeatedly violating the copy-and-paste policy developed at Santa Rosa Memorial Hospital, Santa Rosa, California. “Her use of copy-and-paste impaired continuity of care,” said Alvin Gore, MD, who was involved in the case as the hospital’s director of utilization management. Gore said the hospital warned the doctor, but she did not change her behavior. He did not identify the physician, citing confidentiality. The case occurred more than five years ago. Since then, several physicians have been called onto the carpet for violations of the policy, but no one else has lost privileges, Gore said. Copy-paste practices can save doctors’ time when dealing with cumbersome EHR systems, but they also can lead to redundant, outdated, or inconsistent information that can compromise patient care, experts said. “EHRs are imperfect, time consuming, and somewhat rigid,” said Robert A. Dowling, MD, a practice management consultant for large medical groups. “If physicians can’t easily figure out a complex system, they’re likely to use a workaround like copy-and-paste.” Copy-and-paste abuse has also led to fines. A six-member cardiology group in Somerville, New Jersey, paid a $422,000 fine to the federal government to settle copy-and-paste charges, following an investigation by the Office of the Inspector General of the Department of Health and Human Services, according to the Report on Medicare Compliance. This big settlement, announced in 2016, is a rare case in which physicians were charged with copyand-paste fraud—intentionally using it to enhance reimbursement. More commonly, Medicare contractors identify physicians who unintentionally received overpayments through sloppy copy-and-paste practices, according to a coding and documentation auditor who worked for ten years at a Medicare contractor in Pennsylvania. Such cases are frequent and are handled confidentially, said the auditor, who asked not to be identified. Practices must return Featured Article
Fall 24 www.nvda.org 9 the overpayment, and the physicians involved are “contacted and educated,” she said. Copy-and-paste can also show up in malpractice lawsuits. In a 2012 survey, 53% of professional liability carriers said they had handled an EHR-related malpractice claim, and 71% of those claims included copy-and-paste use. One such case, described by CRICO, a malpractice carrier based in Massachusetts, took place in 2012–2013. “A patient developed amiodarone toxicity because the patient’s history and medications were copied from a previous note that did not document that the patient was already on the medication,” CRICO stated. “If you do face a malpractice claim, copying and pasting the same note repeatedly makes you look clinically inattentive, even if the copy/pasted material is unrelated to the adverse event,” CRICO officials noted in a report. Copy-and-paste is a great timesaver. One study linked its use to lower burnout rates. However, it can easily introduce errors into the medical record. “This can be a huge problem,” Dowling said. “If, for example, you copy forward a previous note that said the patient had blood in their urine ‘six days ago’, it is immediately inaccurate.” Practices can control use of copy-andpaste through coding clerks who read the medical records and then educate doctors when problems crop up. The Pennsylvania auditor, who now works for a large group practice, said the group has very few copyand-paste problems because of her role. “Not charting responsibly rarely happens because I work very closely with the doctors,” she said. Dowling, however, reports that many physicians continue to overuse copyand-paste. He points to a 2022 study which found that, on average, half the clinical note at one health system had been copied and pasted. One solution might be to sanction physicians for overusing copy-andpaste, just as they’re sometimes penalized for not completing their notes on time with a reduction in income or possible termination. Practices could periodically audit medical records for excessive copy-paste use. EHR systems like Epic’s can indicate how much of a doctor’s note has been copied. But Dowling doesn’t know of any practices that do this. “There is little appetite to introduce a new enforcement activity for physicians,” he said. “Physicians would see it just as a way to make their lives more difficult than they already are.” Some hospitals and health systems have gone as far as disabling copy-and-paste function in their EHR systems. However, enterprising physicians have found ways around these blocks. Some institutions have also introduced formal policies, directing doctors on how they can copy-and-paste, including Banner Health in Arizona, Northwell Health in New York, UConn Health in Connecticut, University of Maryland Medical System, and University of Toledo in Ohio. Definitions of what is not acceptable vary, but most of these policies oppose copying someone else’s notes and direct physicians to indicate the origin of pasted material. Santa Rosa Memorial’s policy is quite specific. It still allows some copyand-paste but stipulates that it cannot be used for the chief complaint, the review of systems, the physical examination, and the assessment and plan in the medical record, except when the information can’t be obtained directly from the patient. Also, physicians must summarize test results and provide references to other providers’ notes. Gore said he and a physician educator who works with physicians on clinical documentation proposed the policy about a decade ago. When physicians on staff were asked to comment, some said they would be opposed to a complete ban, but they generally agreed that copy-andpaste was a serious problem that needed to be addressed, he said. The hospital could have simply adopted guidelines, as opposed to rules with consequences, but “we wanted our policy to have teeth,” Gore said. When violators are identified, Gore says he meets with them confidentially and educates them on proper use of copy-and-paste. Sometimes, the department head is brought in. Some physicians go on to violate the policy again and have to attend another meeting, he said, but aside from the one case, no one else has been disciplined. It’s unclear how many physicians have faced consequences for misusing copy-paste features—such data aren’t tracked, and sanctions are likely to be handled confidentially, as a personnel matter. Geisinger Health in Pennsylvania regularly monitors copy-and-paste usage and makes it part of physicians’ professional evaluations, according to a 2022 presentation by a Geisinger official. Meanwhile, even when systems don’t have specific policies, they may still discipline physicians when copy-and-paste leads to errors. » Featured Article
NDA Journal 10 Featured Article Scott MacDonald, MD, chief medical information officer at UC Davis Health in Sacramento, California, told Medscape Medical News that copy-and-paste abuse has come up a few times over the years in investigations of clinical errors. Physicians can be held accountable for copy-and-paste by Medicare contractors and in malpractice lawsuits, but the most obvious way is at their place of work: A practice, hospital, or health system. One physician has lost staff privileges, but more typically, coding clerks or colleagues talk to offending physicians and try to educate them on proper use of copy-and-paste. Educational outreach, however, is often ineffective, said Robert Hirschtick, MD, a retired teaching physician at Northwestern University Feinberg School of Medicine, Chicago, Illinois. “The physician may be directed to take an online course,” he said. “When they take the course, the goal is to get it done with, rather than to learn something new.” Hirschtick’s articles on copy-andpaste, including one titled, “Sloppy and Paste,” have put him at the front lines of the debate. “This is an ethical issue,” he told Medscape Medical News. He agrees that some forms of copy-and-paste are permissible, but in many cases, “it is intellectually dishonest and potentially even plagiarism,” he said. Hirschtick argues that copy-and-paste policies need more teeth. “Tying violations to compensation would be quite effective,” he said. “Even if physicians were rarely penalized, just knowing that it could happen to you might be enough. But I haven’t heard of anyone doing this.” 0 Definitions of what is not acceptable vary, but most of these policies oppose copying someone else’s notes and direct physicians to indicate the origin of pasted material. »
Fall 24 www.nvda.org 11 Dr. Tina Brandon Abbatangelo is an associate professor in-residence at the University of Nevada Las Vegas School of Dental Medicine. She is a graduate of the University of Iowa College of Dentistry. She has earned an MS in public health and is continuing studies in Dental Public Health at UNLV School of Dental Medicine. She is a volunteer secretary for the Peter Emily International Veterinary Dental Foundation (PEIVDF) and the author of the children’s book Animal Dentistry Adventures with Dr. Tabby, Animal Dentist Extraordinaire. Tina Brandon Abbatangelo, DDS In the Tiger’s Mouth: A History of Veterinary Medicine, Part 1 of 4 by: Tina Brandon Abbatangelo, DDS MPH Abstract The discipline of dentistry includes most animals that have a masticatory system and have experienced contact and interaction with humans. This article provides an illuminating account of the historical development of animal dentistry, as well as outlining the future direction of the specialty. Animal dentistry has undergone a complex evolution, with pioneers in the field guiding the way for both dentists and veterinarians. It has transitioned from being a source of financial dependence through equine dentistry to include the dental care of household pets. Through the examination of several animal dentistry cases, we will uncover both the commonalities and distinctions. Animal dentistry is an essential specialty in veterinary medicine that is experiencing growth both economically and in its integrative approach to treating the entire body and its systems. Part 1 History of Veterinary Dentistry The history of teeth among all species mirrors the evolution of the world.1 The narrative shares a ripening story that encompasses science, research, animal welfare, prevention, and technology. The development of human dentistry is comparable to that of veterinary dentistry in that both are vibrant and progressive disciplines. Each field has a unique story to tell. Veterinary dentistry did not come with ease and acceptance due to evidence-based science, modalities in treatment and in organization.2 As a veterinary specialty it has a unique two-part history. This article will focus on the progress made within this specialty of veterinary medicine over time, along with a display of common animal dentistry cases. The first slice of history begins with equine dentistry. The second part brings domestic animals into the story and places us where we are today. It is not surprising to begin with the fact that horses have been considered indispensable and have played a vital role in numerous aspects of human survival. Early veterinary dentistry was primarily concerned with the dental care of equines, but as knowledge of oral pathology, aging characteristics, and other relevant factors in other animals accumulated, the scope of dental care provided by veterinarians expanded to include all animal patients. This expanded knowledge has benefited humans and animals alike. Through confirmation with animal dental experimentation, we have been able to scientifically examine issues such as the development of oral neoplasms, the cause of caries and periodontal disease, and numerous other topics associated with dentistry. Similar The development of human dentistry is comparable to that of veterinary dentistry in that both are vibrant and progressive disciplines. Each field has a unique story to tell. » Featured Article
NDA Journal 12 complications can be observed in the oral cavities of other animals and pets, as our understanding of the pathological processes affecting the human mouth has progressed. The horse has exerted the most evident influence of any domestic animal throughout human history.3 The earliest evidence of equine dentistry was discovered in 1150 BCE in the Mongolian Steppe. Equine veterinary care, specifically concerning oral health, played a crucial role in ensuring the continuation of a strong human-horse relationship because of the limitations imposed by horse biology and available riding apparatus. The preservation of equine health through dental procedures strengthened the critical role of horses throughout economies and cultures across the globe.3 Horses have historically been necessary for transportation, sports, mechanical power, and military use. Strong jaws and teeth were essential to fit their mouths securely, with bits to control and manipulate the horse’s direction and speed.4 To manage occlusal abnormalities, their teeth were intentionally modified (floating) to help accommodate mechanical gags in the horse’s mouth.3 Horse teeth floating, a dental procedure that eliminates the sharp edges that develop on horses’ teeth, is essential to proper bit comfort. Moreover, it creates a uniform grinding pattern for the horse’s chewing, promoting better digestion. There are at least forty teeth in the mouth of an average adult male horse: twenty teeth positioned in the maxillary and twenty in the mandible. Occasionally, the absence of canines in females results in up to four fewer teeth. “Wolf teeth” are present in both sexes. Based on position and structure, horse teeth are classified like human dentition with incisors, canines, premolars, and molars.5 The Triadan system of dental nomenclature for a horse is shown in figure above. The discipline of animal dentistry appeared in Ancient Egypt; nevertheless, its progress has been obstructed due to the Library of Alexandria fire of 48 BC, which destroyed over 700,000 ancient historical manuscripts.6 The ancient Greeks contributed to veterinary dentistry with Simons of Athens writings of The Veterinary Art of the Inspection of Horses in 480 BCE. Aristotle’s History of Animals was written in 333 BCE, where he wrote about horses’ aging teeth and periodontal disease.7,8,9 The Romans also contributed to veterinary dentistry through Chiron, a veterinarian, who wrote a series of animal books with material including equine oral pathology and fractured jaw management.9 The fascination with horses continued into the Byzantine Empire. The interest continued throughout Europe as horse riding and ownership became more progressive among the elite making veterinary medicine an even more essential discipline.10 The origins of small-animal dentistry were independent and gradual. Unfortunately, it began with barbaric procedures that were performed only due to superstitions.4 One example is the excision of the lyssa (the fibro-muscular tube that supports the rostral end of the tongue). The belief that rabies was transmitted by a small “worm!” located at the base of the tongue was widespread. Grattius Falistcus, a poet, (1st century BC), was aware of the legend surrounding the origin of the sublingual ‘lyssa’ of rabid dogs. They held the belief that the dog could be wholly cured by extracting the worms.13 Furthermore, it was suggested that this worm, when injected, possessed miraculous curative abilities capable of averting the disease in the bitten individual; however, this was only the case after the individual had been carried three times around a fire.11 There was even evidence of the fabrication of dog dentures.12 The progressive shift into smaller animal dentistry came when there was an increase in companion animals. Their oral health needs became a priority, and owners paid more attention to the animals’ diets, especially when these animals were no longer hunting for their food. Refined diets brought on more periodontal and oral disease due to reduced masticatory function. The first-ever veterinary dental school was established in 1762 in Lyon, France.13 (photo on page 13) It marked an initial milestone for a shift in veterinary dental teachings. Following this breakthrough in 1889, the first veterinary dental written material was published. Many books followed. These publications expanded the scope of veterinary » Featured Article
Fall 24 www.nvda.org 13 dental techniques beyond equine dentistry to encompass small animal dentistry. Veterinary dentistry originated as an independent discipline within veterinary surgery after the release of “Outlines of Veterinary Medicine and Carnivore Pathology” by Delabere Blain in 1832.14 Although nitrous oxide (N2O) was utilized in human anesthesia since the 1840’s, its prominence in veterinary anesthesia was limited. In 1799, Sir Humphry Davy introduced the notion of implementing nitrous oxide in veterinary medical procedures.16 Despite a limited application period in dentistry, it ultimately proved ineffective in veterinary medicine due to its lack of potency. William Morton, an oral surgeon at Boston Hospital was advised to undertake the anesthesia endeavor. This was followed with the utilization of ether in a tooth extraction in 1846. This became a remarkable advance in the field of veterinary surgery during the 19th century with the introduction of anesthesia. The advancements in human medicine have resulted in favorable developments in the fields of veterinary medicine and veterinary dentistry.15 In current times, nitrous oxide can be used in conjunction with other medications including isoflurane, halothane, and sevoflurane to increase its effectiveness.16 Joseph Bodingbauer, Arthur Mellenby, Louis A. Merillat, Hobday, and Garbutt were among the initial pioneers. During the 1930s, Bodingbauer shed light on the field of small animal dentistry in Vienna. As opposed to horses, dogs, cats, and other small animals gained importance. Arthur Mellenby published a collection of comprehensive papers in 1929 that examined the impact of dietary modifications on the dental health of animals and the progression of dental diseases.17 In the United States, these teachings did not arise until much later. Animal Dentistry and Oral Diseases was published by Merillat in 1905 (Arslan, 2021). Hobday published Surgical Diseases of Dogs and Cats in 1925. Furthermore, dental prevention and prophylaxis were first proposed by Garbutt in 1938.17 There was a significant gap in history until the 1970s. A small but dedicated group of veterinarians created the Veterinary Dental Association (VDA) in 1976. Advances in animal dentistry treatment were initiated by the group. Greater emphasis was placed on the animal masticatory system following the establishment of the organization. The VDA understood the importance of proper oral hygiene and function for an animal’s overall health. By 1987, the VDA recognized dentistry as a specialty in veterinary medicine. These pioneers began consulting zoos for help on veterinary dentistry issues. Their combined knowledge and efforts have contributed to its trajectory today. The specialty has amazingly advanced from a few colleagues conversing over coffee to the founding of a Veterinary Dental College that is widely regarded and forward-thinking. In 2017, The American Veterinary Dental College also introduced a certification program targeted at zoo and wildlife veterinarians. 0 References 1. Emily, Peter P., and Edward R. Eisner, eds. Zoo and Wild Animal Dentistry. John Wiley & Sons, 2021. 2. Lobprise, H. B., & Dodd, J. R. B. (Eds.). (2019). Wiggs’s veterinary dentistry: principles and practice. John Wiley & Sons. 3. Taylor WTT, Tuvshinjargal T (2018) Horseback riding, asymmetry, and changes to the equine skull: Evidence for mounted riding in Mongolia’s Late Bronze Age, Care or Neglect: Evidence of Animal Disease in Archaeology, eds Bartosiewicz L, Gál E (Ox-bow Books, Oxford), pp 134–154. 4. Harvey, C. E. (2021). History of Veterinary Dentistry, Including Development of Oral and Dental Treatment of Wild and Zoo, Safari Park, and Refuge Animals. Zoo and Wild Animal Dentistry, 1–5. 5. Bennett, D. (2017, December). WHAT TEETH CAN TELL YOU: An understanding of the structure and function of normal equine dentition underscores why visits by an equine dentist need to be a regular part of horse care. EQUUS, (483), 49. 6. Trumble, & Marshall, R. M. (2003). The Library of Alexandria. Clarion Books. 7. Erk, N. (1959). İslâm Medeniyeti Çağında Veteriner Tababette Gelişmeler ve “Naserî”. Habl., Yeni Matbaa, Ankara. 8. Erk, N. (1962). Dokuzuncu Yüzyıla Ait “Kitap al-Hayl val-Baytara” Üzerinde Bir İnceleme. A.Ü. Vet. Fak. Derg., VIII, (4), 367–386 9. Erk, N. (1966). Veteriner Tarihi. Ankara Üni. Basımevi. Veteriner Fakültesi Yayınları:195, Ders Kitabı: V+242 S. 10. Easley, K., 1999. Veterinary Dentistry: Its origin and recent history. Journal of Dentistry 47, 83–85. 11. Baer, G. M. (2007). The history of rabies. In Rabies (pp. 1–22). Academic Press. 12. Gardiner, A. (2021). History of veterinary medicine. Handbook of Historical Animal Studies; Roscher, M., Krebber, A., Mizelle, B., Eds, 493–508. 13. Lees, P., Bäumer, W., & Toutain, P. L. (2022). The decline and fall of materia medica and the rise of pharmacology and therapeutics in veterinary medicine. Frontiers in Veterinary Science, 8, 777809. 14. Barber-Lomax, J.W. (1961). Delabere Pritchett Blaine: A Biographical Note. J. Small Animal Practice, 2, 135 15. Smithcors, J. F. (1957). The Evolution of Veterinary Art. Veterinary Medicine. Kansas City, MO. (XVII+408 p.) 16. Duke, T., Caulkett, N., & Tataryn, J. (2006). The effect of nitrous oxide on halothane, isoflurane and sevoflurane requirements in ventilated dogs undergoing ovariohysterectomy. Veterinary Anesthesia and Analgesia., 33(6), 343–350. https://doi.org/10.1111/j.1467-2995.2005.00274.x 17. Arslan, E.S. (2021). A Review on The History of Veterinary Dentistry. Animal Health Production and Hygiene, 10(1), 33–38. Featured Article
NDA Journal 14 August 19, 2024 American Legislative Exchange Council Board of Directors Alexandria, VA RE: ALEC Model Policy on Dental Therapy Dear Members of the ALEC Board of Directors, As America’s leading advocate for oral health, the American Dental Association is committed to advancing access to quality oral health care for all. This includes workforce innovations that allow for dentists to delegate procedures to appropriately educated and trained practitioners, thereby increasing access to care. However, central to this belief is the conviction that in the best interests of the public, only dentists, equipped with comprehensive education and training, are the qualified professionals to diagnose dental disease, identify oral pathology such as oral cancer, perform surgical and irreversible procedures and supervise procedures by allied dental team members. On July 26, 2024, the ALEC Health and Human Services Task force approved, by a vote of 10-9, a model legislation on dental therapy that falls short of meaningfully increasing access to care in an appropriate, timely, and economically feasible way. Therefore, the ADA opposes adoption of this model and asks that you not support its final approval. The dentist is ultimately responsible, ethically and legally, for patient care as acknowledged by the proposed model legislation -- “A supervising dentist shall accept responsibility for all services performed by a dental therapist pursuant to a collaborative management agreement.” The weight of this responsibility requires that the dentist be the healthcare provider that performs examinations/evaluations; diagnoses; treatment planning; and surgical/ irreversible procedures; prescribes work authorizations; prescribes drugs and other medications; and administers enteral, parenteral or inhalational sedation, or general anesthesia. Although the model proposed by the taskforce places the “responsibility of all services performed by a dental therapist” on the dentist, it allows the therapist to: • Conduct an oral evaluation and assessment of dental disease and formulation of an individualized treatment plan. • Evaluate radiographic images. • Administer nitrous oxide. • Perform services such as suture placement, pulpotomy on primary teeth, tooth reimplantation and stabilization, etc. • Perform a nonsurgical extraction of periodontally diseased permanent teeth with tooth mobility. • Directly supervise a dental hygienist and authorize them to perform procedures as well as supervise unlicensed individuals who are allowed to perform “remediable” procedures in accordance with a treatment plan approved by the therapist. We note that “oral evaluation” as defined by the Code on Dental Procedures and Nomenclature (CDT Code) includes a thorough evaluation and recording of the extraoral and intraoral hard and soft tissues including an evaluation for oral cancer, the evaluation and recording of the patient’s dental and medical history and a general health assessment. It may require interpretation of information acquired through additional diagnostic procedures. The purpose of these activities is to reach a fully informed diagnosis and individualized treatment plan for each patient. Given this definition, this model allows a dental Featured Article
Fall 24 www.nvda.org 15 August 19, 2024 Page 2 therapist to diagnose dental disease. The training and education required to perform services as a dental therapist does not prepare individuals to diagnose dental disease, identify oral pathology such as oral cancer and determine an individualized treatment plan. The primary purpose of dentists delegating functions to allied dental personnel is to increase the capacity of the profession to provide patient care while retaining full responsibility for the quality of care. When delegating, the degree of supervision required to assure that treatment is appropriate and does not jeopardize the systemic or oral health of the patient varies with the nature of the procedure and the medical and dental history of the patient, as determined with evaluation and examination. In this context, the proposed model allows a dental therapist to perform services under “general supervision” defined as “the dentist is not present in the dental office or other practice setting or on the premises at the time tasks or procedures are being performed by the dental therapist, but that the tasks or procedures performed by the dental therapist are being performed with the prior knowledge and consent of the dentist”. “Prior knowledge and consent” alone, in our view, is insufficient to support diagnosis, treatment and supervision of other allied personnel. The dentist is the qualified professional to diagnose dental disease, and written standing orders are not a substitute for obtaining a diagnosis. The ADA believes that the development of any new member of the dental team be based upon determination of need, a CODA-accredited dental school or advanced dental education program, and a scope of practice that ensures the protection of the public’s oral health. Failure to specify that dental therapists must graduate from a program accredited by the Commission on Dental Accreditation (CODA), the only body in the United States tasked with evaluating dental education programs, which includes dental therapy; and failure to assure that the patient first become a patient of record examined by the dentist raise significant concerns for the ADA. The ADA believes that any patient to be treated by a dental therapist as authorized by this model legislation must first become a patient of record of a dentist. A patient of record is defined as one who: a. has been examined by the dentist; b. has had a medical and dental history completed and evaluated by the dentist; and c. has had his/her oral condition diagnosed and a treatment plan developed by the dentist. Furthermore, the stipulation around informed consent within this model states the following: “Any dentist or dental therapist who treats a patient shall inform the patient about the availability of reasonable alternate modes of treatment and about the benefits and risks of these treatments. The reasonable dentist standard is the standard for informing a patient under this section. The reasonable dentist standard requires disclosure only of information that a reasonable dentist would know and disclose under the circumstances.” This inappropriately places the burden on the dental therapist to be able to explain treatment plans and alternatives to patients to the same level as a dentist who has much more expansive education and qualifications, all while the dentist takes full responsibility for the actions of the dental therapist. In addition to our concerns expressed above, we maintain that there appears to be little appetite for dental therapy in states that have adopted authorizing legislation. Advocates have long asserted that dental therapy would address dental workforce shortages, particularly in rural areas and other areas with underserved populations. This has not come to fruition. Despite fourteen states having passed some form of dental therapy legislation, most of these states do not have a single therapist practicing or even licensed years after passage of their legislation. While pilot projects exist on tribal lands in Oregon, Washington, and Idaho, the vast majority of dental therapists continue to practice in Minnesota. A report from 2019 indicated that about 73 percent of dental therapists in Minnesota work in a metropolitan areai, and 139 total dental therapists had active licenses in Minnesota as of April 2024ii. The state of Minnesota provides detailed healthcare workforce dataiii, including work status, average hours worked, time spent providing patient care, and other metrics, for dentists, dental hygienists, and dental assistants. However, it does not track such data for dental therapists. This lack of transparency makes it virtually impossible for policymakers to determine whether dental therapists are making a measurable impact in improving access in rural and underserved areas as intended. Featured Article »
NDA Journal 16 August 19, 2024 Page 3 Furthermore, dental therapy education programs exist only in three states – Minnesota, Alaska, and Washington – while dental schools and dental hygiene and dental assisting programs operate in virtually every state in the nation. Earlier this year a dental therapy education program at Metropolitan State University was suspended. We find, as well, that state investment in these programs tends to have a poor return. In Vermont, over $2.6 million in private, state, and federal funds have been spent on a still non-existent program intended for Vermont Technical College (VTC). A 2023 state auditiv identified several critical issues, including the potential misuse of funds as well as an inability of VTC to satisfy the conditions necessary for CODA accreditation. At best, VTC will be unable to enroll any students until 2027, even if all underlying concerns were fixed immediately. We acknowledge that the long-running debate over dental therapy has resulted in good faith efforts by the model’s author to improve upon initial proposals and address concerns in the dental community. However, underlying policy issues lead us to conclude that dental therapy is not a viable dental workforce innovation for state policymakers to pursue. The ADA believes a better and faster approach to address dental workforce shortages is to create state legislation and funding initiatives for existing dental education programs to address the current shortage of hygienists, dental assistants, and expanded function dental assistants who function efficiently in the current dental team model. The ADA encourages states to adopt policies incentivizing dentists and dental hygienists to work in rural and health provider shortage areas serving publicly insured patients by reducing their student loan burden as a quick, cost-effective pathway to help reduce the numbers of underserved populations while simultaneously delivering high-quality care. Community Dental Health Coordinators (CDHCs) who work closely with families to find appropriate care should also be supported within state health policies. We appreciate both your commitment to improving oral health and your diligent review of model legislation before you determine your final position this December. We would welcome the opportunity to meet with you to discuss and develop innovative approaches and best practices we have identified that achieve the goal of improving access to care that are economically viable, expedient, and provide adequate protection of the public’s health. As such, we respectfully request that you do not support the dental therapy model legislation recently passed by the Health and Human Services Task Force. On behalf of the 159,000 members of the American Dental Association, thank you for considering our request. Please contact Jim Schulz, Senior Vice President of Government Affairs, for more information at [email protected]. Sincerely, Linda J. Edgar, D.D.S., M.Ed. President Raymond A. Cohlmia, D.D.S. Executive Director LJE:RAC:js i https://www.health.state.mn.us/data/workforce/oral/docs/2019dt.pdf Featured Article »
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