Dental hygiene and anesthesia: Even government is perplexed by doublespeak

Access to care and local anesthesia administration are passionate topics for me. My beliefs come from a mixture of experience, data, and personal observations.

I have a renewed spirit after reading the Federal Trade Commission statement to the Texas State Board of Dental Examiners. In Texas especially, there has long existed a self-serving double speak amongst the dental community that needs to be addressed. The FTC states that, "competition should be restricted only when necessary to protect against a credible risk of harm, such as health and safety risks to consumers, or fiscal risks to the government" (Gavel, et al., 2014).

There exist many conflicting stances by the TSBDE regarding current topics in dentistry such as: dental service organizations (DSO), local anesthesia administration (LAA) for hygienists, expanded duties for dental assistants, and the permitting of general dentists to do orthodontics, implants, sedation, and other specialty cross-over functions.

I have been privy to the complaints of many dental professionals against the use of DSOs in dentistry. I have also experienced the pros and cons of both private practice and corporate owned dental chains. One of the biggest arguments against DSOs involves abuse of Medicaid and/or aggressive treatment planning.

However, the FTC states that "Incentives for over treatment exist across all dental provider types as virtually all dental care in the U.S. is paid on a fee-for-service quantity-of-care basis" (Gavel, et al., 2014).

My clinical experiences in dentistry include private practice, corporate chain dentistry, and 10 years of varying PRN work. My time working in a corporate dental chain was positive in many aspects: respect for my profession, competitive pay, extensive benefits packages, and retirement planning. The DSO model provides for employee benefits not traditionally seen in private practice dentistry.

Just as each private practice has treatment planning reflective of the practitioners' beliefs, I found the same to be true in corporate dentistry. Each individual office in the chain had varying levels of morale dependent largely upon the dentist's style of leadership and patient care in that particular practice. In my experience, the pressure for dentists and hygienists to meet daily production goals exists equally amongst private practice and DSO managed practices.

Additionally, the infection control procedures I witnessed in DSO practice were ideal and the internal auditing system deterred fraudulent Medicaid claims. The FTC is rightly concerned that the proposed TSBDE rules may prevent better access to care.

Dentists in Texas have restricted hygienists' ability to administer local anesthesia on the grounds of inadequate education, even as evidence profoundly refutes this claim. "Some dentists believe the quality of care would be compromised and patient safety jeopardized because dental hygienists do not have adequate background knowledge to prevent complications and recognize emergencies caused by anesthetics" (Scofield, et al., 2014).

However, there are currently 44 states that allow hygienists to administer local anesthesia and data has shown over a ten-year period that there have been "no reports of disciplinary actions against dental hygienists for the administration of local anesthesia" (Scofield, et al., 2014). The FTC's statement to the TSBDE regarding preventive dental care warrant yet another look into the use of LAA by hygienists. "Reductions in access to dental services, including preventive dental care, could lead to increases in future dental costs and other health care costs" (Gavel, et al., 2014).

This discussion would not be complete without pointing out the irony of the plight for expanded dental assistant duties by the very agency that discusses lack of adequate education as cause to inhibit expanded functions for the dental hygienist. I must also note that many of these same providers find cause to believe that they should expand their own duties into areas traditionally maintained by specialists: oral surgery, implants, orthodontics, sedation, sleep dentistry, and even Botox.

I believe at the heart of these conflicting views is fear over loss of control and perhaps a loss of profit. I remember that there was a time that some dentists fought against the hygiene profession as a whole: fearful over loss of control, fearful over loss of profit, and fearful over reduction in quality of care. Dentists argued that hygienists would not have adequate education to provide quality preventive care. Oh, how we proved that theory wrong!

Additionally, I never bought the argument that the hygiene department could not produce money. At the height of my private practice career, I was bringing in over a quarter of a million dollars in revenue for a total profit after cost and salary of over $80,000 for the practice. Dental hygienists are highly educated preventive specialists that make dentists a lot of money.

Therefore, in order to continue towards the progression of the profession of dental hygiene, I must stand with the FTC in their statement deterring the TSBDE from enacting monopolizing laws, "For these reasons, we urge the Board to consider the potential anticompetitive effects of the proposed rules, including higher prices and reduced access to dental services, especially for underserved populations, and to reject both proposed 108.70 and 108.74" (Gavel et. al, 2014).

With this in mind, I urge our legislators to support bills that allow dental hygienists to administer local anesthesia and increase the access to oral healthcare in Texas.

References

1. Gavel AI, Vita MG, Feinstein D. Response for Public Comment to Texas State Board of Dental Examiners. Washington D.C.: Federal Trade Commission, 2014. Web. 6 Oct. 2014.
2. Scofield JC, Gutmann ME, DeWald JP, Campbell PR. "Disciplinary actions associated with the administration of local anesthetics against dentists and dental hygienists." Scientific Publication.