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departments
5 The Editor/The Road to Here
7 Letter to the Editor
10 Journal Reviewers
13 Impressions
21 CDA Presents
81 Classifieds
92 Advertiser Index 94 Dr. Bob/My Dream: To Sleep 13
features
28 CDA Research An introduction to the issue. Kerry K. Carney, DDS
31 California’s State Oral Health Infrastructure: Opportunities for Improvement and Funding Based on a literature review and interviews with 15 oral health officials nationally, the paper recommends hiring a state dental director with public health experience, developing a state oral health plan, and seeking federal and private funding to support an office of oral health. Joel Diringer, JD, MPH, and Kathy R. Phipps, DrPH, RDH
39 Advanced Dental Education Programs: Status and Implications for Access to Care in California This article reviews the history of primary care residencies and their potential to positively affect access to care in the future. Paul Glassman, DDS, MA, MBA
49 Economic Feasibility of Alternative Practitioners for Provision of Dental Care to the Underserved This study assesses the viability of alternative practitioner models for dental therapists, dental health aide therapists, and advanced dental hygiene practitioners for provision of dental care to the underserved. Anne Matthiesen, MHA, MBA
65 Are Procedures Performed by Dental Auxiliaries Safe and of Comparable Quality? A Systematic Review The objective of the current study was to systematically evaluate the existing evidence in relation to the safety, quality, productivity or cost-benefit, and patient satisfaction of the procedures performed by the different groups of dental providers. Summary results of individual studies are presented and critically evaluated. A.P. Dasanayake, BDS, MPH, PhD; B.S. Brar, MS; S. Matta, DDS; V. K. Ranjan, BDS, MS; and R.G. Norman, MS, PhD
january 2012 3 cda journal, vol 40, nº 1
CDA Journal Volume 40, Number 1 Journal january 2012
Crystan Ritter Reader Guide: administrative assistant Upcoming Topics Letters to the Editor february: Sleep- Kerry K. Carney, DDS Advertising Disordered Breathing [email protected] Journal of the California Corey Gerhard march: CDA Research Dental Association advertising manager april: Oral Health Literacy Subscriptions The subscription rate is published by the Jenaé Gruchow Manuscript Submissions $18 for all active members California Dental traffic/project Patty Reyes, CDE of the association. The Association coordinator assistant editor subscription rate for 1201 K St., 14th Floor [email protected] others is as follows: Sacramento, CA 95814 Production 916-554-5333 Non-CDA members and 800.232.7645 Matt Mullin Author guidelines institutional: $40 cda.org cover design are available at Non-ADA member cda.org/publications/ dentists: $75 Management Randi Taylor journal_of_the_california_ Foreign: $80 Kerry K. Carney, DDS graphic design dental_association/ Single copies: $10 editor-in-chief submit_a_manuscript Subscriptions may This [email protected] commence at any time. Kathie Nute, Western Type preproduction Classified Advertising Please contact: Ruchi K. Sahota, DDS, CDE Jenaé Gruchow Crystan Ritter associate editor California Dental traffic/project administrative is why Association coordinator assistant Brian K. Shue, DDS Daniel G. Davidson, DMD [email protected] [email protected] associate editor president 916-554-5332 916-554-5318 [email protected] Peter A. DuBois Display Advertising Permission and Reprints we’re executive director Lindsey A. Robinson, DDS Corey Gerhard Jeanne Marie Tokunaga president-elect advertising manager publications manager Jennifer George [email protected] [email protected] JeanneMarie.Tokunaga@ vice president, 916-554-5304 cda.org marketing and James D. Stephens, DDS 916-554-5330 here. communications vice president [email protected] Journal of the California Dental Association (issn Alicia Malaby When you give to the 1043-2256) is published monthly by the California Dental communications Walter G. Weber, DDS Association, 1201 K St., 16th Floor, Sacramento, CA 95814, director secretary CDA Foundation, you help 916-554-5330. Periodicals postage paid at Sacramento, [email protected] Calif. Postmaster: Send address changes to Journal fund local clinics, support Jeanne Marie Tokunaga of the California Dental Association, P.O. Box 13749, publications manager Clelan G. Ehrler, DDS dentists who serve in rural Sacramento, CA 95853. treasurer areas, and give countless Jack F. Conley, DDS [email protected] The Journal of the California Dental Association is published editor emeritus kids healthy, happy smiles. under the supervision of CDA’s editorial staff. Neither the Alan L. Felsenfeld, DDS editorial staff, the editor, nor the association are responsible Editorial speaker of the house for any expression of opinion or statement of fact, all of cdafoundation.org Robert E. Horseman, DDS [email protected] which are published solely on the authority of the author contributing editor whose name is indicated. The association reserves the Andrew P. Soderstrom, DDS right to illustrate, reduce, revise, or reject any manuscript Patty Reyes, CDE immediate past submitted. Articles are considered for publication on assistant editor president condition that they are contributed solely to the Journal. [email protected] Courtney Grant Copyright 2012 by the California Dental Association. communications coordinator
4 january 2012 Editor cda journal, vol 40, n 1 º
The Road to Here
kerry k. carney, dds
he January and March issues of the Journal of the California In 2002, the CDA House adopted Dental Association will present reports and research pertaining Resolution 28 approving a position to the question of addressing Tbarriers to oral health care in our state. paper on access to care. The California Dental Association com- missioned this research. The research presented in these issues is the result of a journey that began years ago. participation in order to move closer to ditional areas of study that would provide After the publication of the “2000 Oral solutions that will and should go well the data from which suggestions and an Health in America: A Report of the Sur- beyond the resources of the [CDA].”1 action plan or roadmap could be crafted. geon General,” organized dentistry became Conducting research is not new to the In 2010, an interim report was made engaged with the issue to a significant association. Since 2006, the CDA Founda- to the house describing the activities of degree. The surgeon general’s report was tion has commissioned studies on the de- the taskforce and the workgroup and the published nearly 12 years ago and was the livery of oral health services in California research completed up to that time.3 The first national report to identify “… access in order to determine the most strategic project objectives and success criteria to [oral health] care as an issue in need of use of its resources. The Forecasting were delineated in the report. immediate resolve to reduce the dispari- Research Workgroup, a subcommittee of CDA commissioned research has been ties among all populations.”1 The surgeon volunteers under the Policy Development available on line for some time. (cda.org/ general’s report recommended the creation Council, oversaw this research. advocacy_&_the_law/access_to_care/ of “ … a communitywide partnership to In 2008, the house adopted resolu- forums/access_report. Member log-in reduce oral health disparities, change oral tion 36S1-2008-H that directed CDA to required.) The January and March issues health perceptions among the public and undertake comprehensive study aimed of the Journal make the research available policy-makers, develop a scientific and at improving the access to dental care for in a more reader-friendly form. evidence-based approach, an improved the underserved populations.This direc- The CDA House of Delegates took ac- infrastructure that would integrate oral tive was referred to the Policy Develop- tions to bring their members information health into general health and the removal ment Council and two groups of volun- and analysis to help in understanding the of barriers between individuals and the teers were formed. Due to the increased scope and breadth of the issue at hand. oral health services they require.2 national activity on workforce-specific This is information pertinent to the In 2002, the CDA House adopted proposals and the need for research in discussion of overcoming barriers to re- Resolution 28 approving a position paper this area, the former Forecasting Re- ceiving oral health care services in Califor- on access to care. Recognizing the scope search Workgroup became the Workforce nia. This is information to help dentistry and complexity of the problem, that posi- and Forecasting Research Task Force. The protect and promote the delivery system tion paper stated, “… the association and second group was a new workgroup; it that works for more than 70 percent of its members acknowledge that access to was called the Access Workgroup. the population while improving access to dental care is a multifaceted issue that will “The focus of both groups … [was] … dental care for the nearly 30 percent of require multiagency and multiorganiza- to improve access to dental care for the the population that experiences barriers tional cooperation in order to adequately nearly 30 percent of the population that to care now. address the challenges associated with experiences barriers to care now while Peruse these papers, consider them improving access. Thus, addressing ac- preserving the dental delivery system for critically, draw your conclusions, and cess to care will require public, private, the 70 percent which it serves well.”3 In participate in the discussion. professional, business, and government 2009, the access workgroup developed ad- continues on 6
january 2012 5 jan. 12 editor cda journal, vol 40, nº 1
editor, continued from 5 references 1. Res 28-2002-H: Position paper on access to care, CDA policy manual, page A-2. 2. U.S. Department of Health and Human Services. Oral Health in America: A report of the surgeon general. 2000 3. Resolution 31, 2010, Resolution 31, Access to Care. The Journal of the California Dental Association welcomes letters. We reserve the right to edit all communi- cations and require that all letters be signed. Letters should discuss an item published in the Journal within the past two months or mat- ters of general interest to our readership. Let- ters must be no more than 500 words and cite no more than five references. No illustrations will be accepted. Letters may be submitted via e-mail to the Journal editor-in-chief at kerry. [email protected]. By sending the letter to the Journal, the author certifies that neither the letter nor one with substantially similar content under the writer’s authorship has been published or is being considered for publica- tion elsewhere, and the author acknowledges and agrees that the letter and all rights of the author with regard to the letter become the property of the California Dental Association.
6 january 2012 Letter cda journal, vol 40, n 1 º
CDA Takes Important Step for Access
Editor: organization in the country. By our actions know works so well and is the pride of oral About 3½ years ago, a group of doctors at this house and the preceding few years, care worldwide, and close the gap for those from Alameda County convened a meeting we have shown the world that we are truly outside this system. In fact, it is the very to discuss what was then called “the access a part of the solution to access to care in comprehensive nature of this plan that problem.” We wanted to know the size and our communities — indeed we may be the makes it so special. Its text proposes “doing scope of the problem and soon realized only organization that has such a thorough the right thing” for our profession and for that there was no one access problem but knowledge of the issues at play here. the patients we serve in our communities. a constellation of different barriers to Through this amazing and difficult I am reminded of that famous quote receiving care — many of which we could process, we now have the tools to answer widely attributed to Margaret Mead that easily identify, and some that we knew our critics, regulators, legislators, commu- we have all seen hundreds of times, but it were inherently more difficult to categorize nity organizations, think-tanks and others fits so well here, “Never doubt that a small and understand. We also realized that there when they point the accusing finger at us group of thoughtful, committed citizens was no one repository of information about and say “If only dentistry were different ...” can change the world; indeed, it’s the only existing resources to meet these various We know that with the bold moves thing that ever has.” barriers to care in our communities. taken here in this organization, we can Thank you again from your colleagues We drafted a resolution aimed at ana- confidently move forward, together, to at Alameda County. This is clearly ground- lyzing the various access issues, catalogu- make California a better place for the breaking and a time for celebration! ing existing community service, proposing 70 percent of Californians enjoying the gary l. dougan, dds, mph loan repayment programs for young den- mainstream dental delivery model that we Oakland, Calif. tists, and increasing reimbursement levels to dentists participating in Medi-Cal. This draft resolution was then dis- cussed with our sister components in the East Bay and became Resolution 36 “Access Missing a Journal? to Care Analysis” at the 2008 CDA House of Delegates. It passed overwhelmingly. What followed was an amazing miracle. Dentistry as a profession would be under attack from various organizations pointing the fingers at us to be the solution of the problem, as though we somehow created population and health disparities. Health care reform would become a national initiative. The economy would drastically affect our lives and the lives of our patients and fellow citizens, and on and on. Undaunted, CDA assembled two groups of volunteers that were given great latitude to research and fully catalogue and under- stand the various access- and barriers-to- All issues back to care issues. After three years of deliberative, 1998 are available thoughtful review, CDA has approved a at cda.org comprehensive plan that flies in the face of No password required. anyone seeking to propose shotgun, cherry- picking solutions to a problem that we know is immense and multifactorial. I want to acknowledge and congratu- late CDA and the 2011 House of Delegates for being the most forward-thinking dental
january 2012 7
Journal_archive_1_6th_vert.indd 1 6/23/11 9:09 AM Stories. Everybody has one. Some people have a career. The lucky ones have a calling, a passion for dentistry that likely began in an illuminating moment. For some, it was the first time they set foot in a dental office, or the magic of seeing a tooth that came back to life. But whatever your story, the reasons to join CDA are clear— advocacy, protection, education, support and being part of an organization dedicated to improving the oral health of all Californians. Join. Renew. Share. cda.org/member
James Forester, DDS
Growing up with dentistry. As a dentist’s son, James Forester can’t remember a time when he didn’t want to be a dentist. When he was in kindergarten, he’d draw his future practice, complete with pizza parlor and the requisite bowling alley. He started hanging out at his dad’s office at a really young age and worked for him during both high school and college. Today, he Progress. specializes in pediatric dentistry and serves low-income families at La Clinica It’s what happens when de Tolosa in Paso Robles. 25,000 dentists work together.
journal_double_jan1.indd 2-3 12/13/11 1:47 PM Stories. Everybody has one. Some people have a career. The lucky ones have a calling, a passion for dentistry that likely began in an illuminating moment. For some, it was the first time they set foot in a dental office, or the magic of seeing a tooth that came back to life. But whatever your story, the reasons to join CDA are clear— advocacy, protection, education, support and being part of an organization dedicated to improving the oral health of all Californians. Join. Renew. Share. cda.org/member
James Forester, DDS
Growing up with dentistry. As a dentist’s son, James Forester can’t remember a time when he didn’t want to be a dentist. When he was in kindergarten, he’d draw his future practice, complete with pizza parlor and the requisite bowling alley. He started hanging out at his dad’s office at a really young age and worked for him during both high school and college. Today, he Progress. specializes in pediatric dentistry and serves low-income families at La Clinica It’s what happens when de Tolosa in Paso Robles. 25,000 dentists work together.
journal_double_jan1.indd 2-3 12/13/11 1:47 PM Reviewers cda journal, vol 40, n 1 º
Thank You to the Journal Reviewers
Ibtisam Al-Hashimi, BDS, MS, PhD Fred W. Kamansky, DDS Greg Alterton Richard T. Kao, DDS, PhD Gary C. Armitage, DDS Nate Kaufman, DDS Jane C. Atkinson, DDS Ernest B. Kenney, DDS Leif K. Bakland, DDS Robert D. Kiger, DDS Rahmat A. Barkhordar, DDS Satish Kumar, DDS William F. Bird, DDS Oanh Le, DDS Authors have their names on their articles. Carolyn Brown, DDS Thomas K. Lee, DDS Contributing editors, staff members, and Alan Budenz, DDS Karen Matsumura-Lem, DDS
outside vendors have their names in the Kerry K. Carney, DDS Peter M. Loomer, DDS Joseph M. Caruso, DDS William P. Lundergan, DDS masthead. But there are more people Winston Chee, DDS Cindy Lyon, RDH, DDS, PhD involved in putting out the Journal than Charles Cobb, DDS, PhD Charles McNeill III, DDS those whose names are printed in each Stephen Cohen, DDS William W. Morgan, DDS
issue. There are also the professionals Max Z. Crigger, DDS Larry Morrill, DDS Michael J. Danford, DDS Mahvash Navazesh, DMD who formally review manuscripts and Robert Danforth, DDS Brian Novy, DDS offer their recommendations. Below is a Troy E. Daniels, DDS Hessam Nowzari, DDS list of the people whose reward comes Paul Denny, PhD Howard F. Pollick, BDS, MPH
in the form of a thank you letter and a Spomenka Djordjevic, DDS, MSPH David W. Richards, DDS, PhD Clifton O. Dummett, DDS Lindsey A. Robinson, DDS listing here. In addition, there are many Alan L. Felsenfeld, DDS Donald P. Rollofson, DMD others who have provided information Jane L. Forrest, RDH, EdD Steven E. Schonfeld, DDS counsel to the Journal. It is impossible Debi Gerger, RDH, MPH Jeffrey Sense, DDS
to list them all. The Journal extends its Jane Gillette, DDS Brian K. Shue, DDS Lisa Anne Harpenau, DDS Richard S. Sobel, DDS thanks to the following people and every- Thomas T. Henderson, MSPH Vladimir Spolsky, DMD, MPH one else who assists us in our endeavor. Jeffrey M. Henkin, DDS Charles Stewart, DDS Edmond Hewlett, DDS Thomas H. Stewart, DDS Irene V. Hilton, DDS Sotirios Tetradis, DDS, PhD Allen Hindin, DDS Ray Tozzi, DDS Chester Hsu, DDS Jane Weintraub, DDS, MPH Ronald K. Hunter, DDS David Won, DMD, DMSc Peter F. Johnson, DMD Allen Wong, DDS Barbara Kabes, DDS, MS A. Jeffrey Wood, DDS
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Customer Service Key to Patients Returning by alicia malaby Nordstrom, Ritz-Carlton, and Zappos. These companies may sell different products and services but share a unique quality that goes beyond shoes and hospitality. Simply put, they offer exceptional customer service that distinguishes them from competitors. Whether it’s personal shopping, upgrades on a room, or generous return policies, exceptional customer service cre- ates loyalty that keeps people coming back time and time again. Imagine how your dental practice might benefit if you could create a Nord- strom-type experience for your patients. “What is it that sets your practice apart from everybody else?” asked Judy Kay Mausolf, president of Practice Solutions, Inc. “There are little things you can do that Deborah Zemke Deborah make patients feel that they’ve been seen,
continues on 19
Jaw Size Decreases as We Get Older Wrinkles, thinning hair and going gray are all part of the natural aging process. Researchers now are adding shrinking jaws to that list. In a study that began in 1949, plaster moulds were made of the jaws of dental students who were then in their 20s. The process was repeated twice when the participants were in their 30s and 40s. During that final round, researchers were able to contact 18 of the original 30 subjects. “We found that over these 40 years there was less and less room for teeth in the jaw,” says Lars Bondemark, DDS, professor of orthodontics, who analyzed the material together with his colleague Maria Nilner, DDS, professor of clinical bite physiology at the College of Dentistry, Malmö University, in Sweden. “This crowdedness comes from shrinkage of the jaw, primarily the lower jaw, both in length and width. While this is only a matter of a few millimeters, it is enough to crowd the front teeth. “We can also eliminate wisdom teeth as the cause, because even people who have no wisdom teeth have crowded front teeth,” Bondemark said. The reason for the shrinkage still is not known but more likely based on factors including heredity, anatomy, and the condition of the patient’s bite. Also, while the amount of reduction varies from person to person, for some, it might be enough for them to perceive something is happening to their bite. “In that case, it’s good to know that this is normal,” says Bondemark, who maintains that dentists need to take into consideration the continuous shrinking of the jaws when they plan to perform major bite constructions on their patients. “We’re working against nature and it’s hard to construct something that is completely stable.”
january 2012 13 jan. 12 impressions cda journal, vol 40, nº 1
Researchers Using Whole Genome who are caries-free. Sampling and collec- Sequencing to ID Caries-Causing Bacteria tion will take place at Bellevue Hospital While it has been known for nearly a Center in New York. century that a link exists between Lacto- “The findings from our new study, as bacilli bacteria (Lb) and severe early child- well as the earlier research on Streptococ- hood caries, figuring out which of the cus mutans, will help propel the develop- strains is accountable remains a mystery, ment of a diagnostic test that dentists but hopefully not for much longer. can administer chairside to identify A New York University dental research those at risk,” Caufield said. team recently received a four-year, $2.2 Added Li, “Severe early childhood million dollar grant from the National caries is one of the most prevalent Institute of Dental and Craniofacial chronic diseases in underprivileged Research, part of the National Institutes populations. Much still needs to be of Health, to use whole genome sequenc- learned about how the disease develops, ing to identify those strains of Lb that and how it can be prevented. Our study contribute to the development of severe will help to fill those gaps.” early childhood caries. Sequencing will be conducted by Page W. Caufield, DDS, PhD, professor co-investigators at University College in of cariology and comprehensive care, and Ireland and at the Wellcome Trust Sanger Yihong Li, DDS, MPH, DrPH, professor Institute in the United Kingdom, accord- of basic science and craniofacial biology, ing to a news release. Caufield and Li will the study’s principal investigators, will collaborate with experts on bacterial ge- analyze several hundred bacteria samples nome evolution at the American Museum from children who have severe early of Natural History to identify sequences childhood caries and their parents, as common to children with severe early well as from children and their parents childhood caries and to their parents.
Research Conducted on Effect of Handpieces on Dentists’ Hearing The National Hearing Conservation Association Foundation is helping fund a study on the impact dental handpieces are having on dental professionals. Krisztina Bucsi Johnson, an eight-year dental assistant and a doctoral student at East Tennessee State University, is conducting the research on whether dentists can lose their hearing due to dental handpieces. Johnson is recruiting dentists in the area for her study to which the NHCAF has provided $5,000 in support. Using portable instruments in dental offices, Johnson will evaluate the dentist’s hearing at the beginning and ending of each day. While some research already has been done on this topic, Johnson said she wanted to gather more data and details.
14 january 2012 cda journal, vol 40, nº 1
Frequent Activity Throughout the Day May Reduce Cancer Risk Keep moving. That’s what experts from the American Institute for Cancer Research recently said in a plea to some employers and employees and to rethink physical activity as new research has confirmed that staying in motion may reduce the risk of cancer. At the annual Research Conference on Food, Nutrition and Physical Activity, the AICR cited a direct link between “sitting time” and rates of breast and colon cancers: 49,000 cases of breast cancer and 43,000 cases of colon cancer occurring in the United States annually were the direct result of a lack of physical activity. Additionally, the report further said that daily walking reduces a number of biological indicators of cancer risks including insulin resistance, inflammation, obesity, and hormone levels. Researchers also cautioned that sitting for long periods of time dramatically increased cancer risks, even among individuals who exercise daily. “Taken together, this research suggests that every day, we’re each given numerous opportunities to be active and protect ourselves from cancer, not one,” said Alice Bender, AICR spokesperson. Bender also said that the mindset of American employers and employees regarding the difference between exercise and movement and its impact on health needs to be changed. “A person who gets up in the morning and makes time by spending 30 minutes on the treadmill probably feels pretty pleased with himself, and he should. He’s making excellent progress and doing a lot more than most Americans. For those 30 minutes, he’s hard at work lowering those cancer risk indicators.
Caries Prevention May Be in Form A in saliva of animals by intranasal immuniza- of DNA Vaccine tion with pGJA-P/VAX plus salmonella. Researchers have demonstrated that While challenges continue because of anti-caries DNA vaccines, including the low immunogenicity of DNA vac- pGJA-P/VAX, are holding promise in cines, Shi found that enhanced surface preventing caries. protein immunoglobulin A responses in Wei Shi of the Wuhan Institute of Virol- saliva were associated with inhibition of S. ogy, Chinese Academy of Sciences, and his mutans colonization of tooth surfaces and team of researchers, published their study, endowed better protection with signifi- “Flagellin Enhances Saliva Ig A Response and cant less carious lesions. Protection of Anti-caries DNA Vaccine,” in The study further demonstrated that an issue of the Journal of Dental Research, the recombinant salmonella could enhance official publication of the International and specific immunoglobulin A responses in American Associations for Dental Research. saliva and protective ability of pGJA-P/ Using recombinant flagellin protein VAX, providing an effective mucosal adju- derived from salmonella as mucosal adjuvant vant candidate for intranasal immuniza- for anti-caries DNA vaccine (pGJA-P/VAX), tion of an anti-caries DNA vaccine. the team analyzed the effects of salmonella A corresponding perspective article, protein on the serum surface protein im- “Prospects in Caries Vaccine Development,” munoglobulin G and saliva surface protein was written by Daniel Smith of the Forsyth immunoglobulin A antibody responses, the Institute. Smith wrote that DNA vaccine colonization of Streptococcus mutans (S. mu- approaches for dental caries have had a tans) on rodent teeth, and the formation of history of success in animal models. Dental caries lesions, according to a news release. The caries vaccines, directed to key components results showed that salmonella promoted the of S. mutans colonization and enhanced production of surface protein immunoglobu- by safe and effective adjuvant and optimal lin G in serum and secretory immunoglobulin delivery vehicles, are likely imminent.
january 2012 15 Everyone knows you can do a composite in your sleep.
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Journal_compass_Dec2011_rightside.indd 1 12/20/11 2:37 PM jan. 12 impressions cda journal, vol 40, nº 1
Obesity-Periodontitis Link? with a healthy periodontium. Two mi- Obesity or periodontal disease-modi- croRNA species (miR-30e,miR-106b) were fied microRNA expression and potential up-regulated in nonobese subjects with interaction between obesity and periodon- periodontal disease and in the presence titis that could involve microRNA modula- of periodontal disease and obesity, and tion were the subjects of a recent study nine microRNAs were significantly up- titled, “MicroRNA Modulation in Obesity regulated (miR-15a,miR-18a,miR-22,miR- and Periodontitis,” and published in the 30d,miR-30e,miR-103,miR-106b, miR- Journal of Dental Research, the official pub- 130a,miR-142-3p,miR-185 and miR-210). lication of the International and American The authors concluded that the data were Associations for Dental Research. consistent with the concept that miRNA Total RNA was extracted from gin- that are induced by chronic nutritional gival biopsy samples collected from 20 stress leading to obesity may also non- patients in four groups (five nonobese parsimoniously modulate inflammatory [BMI < 30kg/m2] participants with a pathways within periodontal tissues and healthy periodontium; five nonobese affect disease expression. participants with periodontitis; five “The expression of specific microRNA obese [BMI > 30kg/m2] participants species in obesity provides new insight into with a healthy periodontium; and five possible mechanisms of how risk factors obese participants with periodontitis), might modify periodontal inflammation according to a news release. Two mi- and may represent novel therapeutic targets,” croRNA species (miR-18a, miR-30e) were said William Giannobile, DDS, MS, DMSc, up-regulated among obese individuals Journal of Dental Research’s editor in chief.
Mouth Cancer Cases Expected to Continue Increasing It is forecasted that more than 790,000 people worldwide will be diagnosed with mouth cancer by 2030, an increase of more than 63 percent compared to 2008, according to the International Agency for Research on Cancer. Most of the risks for mouth cancer are related to one’s lifestyle: tobacco use and alcohol abuse. Excessive drinking can increase risk by up to four times; those who smoke (even smokeless tobacco and the chewing variety) and drink are up to 30 times more likely to develop the disease. It is predicted that more than 460,000 people will die from mouth cancer, more than two-thirds (67.6 percent) higher than 2008 rates. As such, the World Health Organization believes “modifying and avoiding” risk factors could result in up to 30 percent of cancers being avoided, according to a news release. Nigel Carter, DDS, chief executive of the International Dental Health Foundation, said greater worldwide knowledge on mouth cancer and associated risk factors could have a major influence on the lives of millions. “Although cancer is not wholly preventable, mouth cancer is very closely related to lifestyle choices. Making more people aware of the risks and symptoms for mouth cancer will undoubtedly save lives,” Carter said. “We know that early detection can transform survival rates from 50 percent to 90 percent and simple campaigns like these — supported by health professionals — can make a real difference.” Routinely checking for warning signs, Carter said, is something everyone can do. “These include ulcers that do not heal within three weeks, red and white patches in the mouth, and unusual lumps or swellings in the mouth.”
18 january 2012 cda journal, vol 40, nº 1
Graft Prevents Gum Recession Following Implant After a tooth has been replaced with an implant, gum recession can be a real concern. Areas of root are exposed, which can be painful for the patient. In a recent issue of the Journal of Oral Implantology, a report was presented on a case series of 10 people who received a single immediate tooth replacement with a subepithelial connective tissue graft, which proved successful in making gingival tissue more resistant to recession. In the procedure, a failing tooth was removed and an implant was immediately placed into the socket. Tissue was then harvested from the palate using a single incision. The graft material was inserted into a prepared space between the labial bony plate and the gingiva of the extraction site. The graft preserved soft-tissue levels, making the gum less likely to recede, according to the authors. Another way to measure the success of an implant is with the marginal bone level, which can be influenced by the way the abutment and implants unite. “Platform switching” refers to the size discrepancy between these two components and can be useful in preserving the marginal bone level.
customer service, continued from 13 they’ve been heard and they’re special.” “We have to kill our patients with dropped, “said Mausolf, who encour- Mausolf, a motivational speaker with kindness and figure out a way to make aged dental practices to cross-train two decades of experience as a dental of- them feel comfortable so every visit is team members to perform other jobs in fice manager, outlined the positive impact special,” said Mausolf, who also cautioned the office as long as it’s legal and within of exceptional customer service during her that all team members need to be on their scope of licensure. “You can’t have September lecture at CDA Presents in San board with the concept. “You’re only as great customer service if a team mem- Francisco, “People Will Forget Everything strong as your weakest link – one bad ber has a bad attitude — it’s everyone Except How You Made Them Feel — The apple changes it and you’ve lost a patient.” helping everyone whenever they can to Secret is in the Service.” Care is Mausolf’s third component of focus on the patient and their needs.” According to Mausolf, the secret to value, which includes a patient-focused By doing so, a patient can experience providing customer service starts with experience rather than an individual task- smooth transitions and handoffs between three components of value: connection, focused appointment. team members responsible for briefing consistency, and care. “People want to know that you actually each other on a patient’s completed treat- “We need to connect with people on a care about them,” stated Mausolf. “If you ment and future appointment needs. personal basis,” said Mausolf, who urged want someone to know that you care, you “Customer service is follow-up, too. We front office dental team members to need to slow down and ask questions — may think we’re bugging our patients, but answer the phone as if it were their most ask if they have any questions about the if a patient says they’ll call and they don’t, important task of the day. “Find out from suggested treatment plan. When you lose give the person a call to find out what’s patients why they want to come to the connections with patients that’s why they going on,” said Mausolf. office — focus on their wants, needs, and go to another office.” Above all, Mausolf, who’s known for desires. You want to ask open-ended ques- Mausolf urged dental professionals to her affinity for smiley faces and wearing the tions and let them talk, the 80-20 rule.” be extra considerate of anxious patients color orange, stated the easiest thing dental After connecting with patients, and reinforce with them how well they do team members can do to ensure exceptional Mausolf advised dental practices to during appointments, as well as thanking customer service in the office is to smile. offer consistency in their customer ser- all patients for coming in to the office. “How many of you smile consistently in vice by treating every patient the same, “Patients become a number 1 prior- your office?” asked Mausolf. “Most of you every time they step foot in the door. ity, everything else you’re doing gets have great teeth, so show them, smile!”
january 2012 19 jan. 12 impressions cda journal, vol 40, nº 1
Sweet! Licorice Root Extract Helps “The use of the licorice root lollipops is Zap Caries-Causing Bacteria an ideal approach as it will stop the transfer A study has found that lollipops con- and implantation of the bacteria that cause taining the extract of licorice root drasti- dental decay from mothers to their infants cally decreased the bacteria that triggers and toddlers,” said Martin Curzon, editor-in- tooth decay, especially in preschool-age chief, European Academy of Pediatric Dentistry. children who have a high risk of caries. “It also has the merit of being a low-cost The orange-flavored, sugarless lollipops high-impact public dental health measure.” containing licorice root extract were de- The study was funded by the Re- veloped using FDA-approved materials by search and Data Institute of the affiliated Wenyuan Shi, PhD, a microbiologist at the companies of Delta Dental of Michigan, University of California, Los Angeles, and Ohio, Indiana, Tennessee, Kentucky, New C3 Jian, Inc., a research and development Mexico, and North Carolina. The inves- company in California, according to a news tigation was a collaborative effort of the release. The lollipops are manufactured by Greater Lansing Area Head Start Program, Dr. John’s Candies of Grand Rapids, Mich. the University of Michigan, and UCLA. In the study, 66 preschool students Delta Dental’s Research and Data Institute aged 2 to 5 and enrolled in a Head Start provided the grants as part of its mission Program in Michigan were given a lollipop to remain on the cutting edge of finding for 10 minutes twice a day for three weeks. solutions to oral health problems. Results showed a significant reduction “Dental decay is one of the most com- in Streptococcus mutans, the primary bacte- mon childhood diseases with more than ria responsible for tooth decay, during the half of children ages 5 to 17 having had three-week period when the lollipops were at least one cavity or filling,” said Jed J. being used and lasting for an additional 22 Jacobson, DDS, MS, MPH, chief science days before beginning to rebound, accord- officer at Delta Dental. “We are working to ing to a news release. Using a saliva test, find simple, effective regimens that will en- the amount of S. mutans in the patient’s courage prevention and control of dental mouth was measured before and during disease. While the results of this pilot clini- the three-week period where lollipops were cal trial are encouraging, more research is used, as well as for several weeks thereafter. needed to confirm these early findings.”
upcoming meetings
2012
March 29– CSPD/WSPD Annual Meeting, Portland, Ore., [email protected] April 1
April 22–28 United States Dental Tennis Association’s 45th Annual Spring Meeting, Kiawah Island, S.C., www.dentaltennis.org or 800-445-2524
April 26–28 World Federation for Laser Dentistry, 13th Annual World Congress, Barcelona, Spain, wfldbcn2012.com
May 3–5 CDA Presents the Art and Science of Dentistry, Anaheim, 800-CDA-SMILE (232-7645), cdapresents.com
Oct. 18–23 ADA 153rd Annual Session, San Francisco, ada.org
To have an event included on this list of nonprofit association continuing education meetings, please send the information to Upcoming Meetings, CDA Journal, 1201 K St., 16th Floor, Sacramento, CA 95814 or fax the information to 916-554-5962.
20 january 2012 Presents_ANA2012_savedate_REV1.pdf 1 8/18/11 3:00 PM
PRESENTS
The Art and Science of Dentistry
Save the date!
C
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CM Anaheim, MY California
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CMY
K Thursday- Saturday May 3-5, 2012
cdapresents.com CDA Presents Headlining Speakers
Lee Ann Brady, DMD Terence E. Donovan, DDS
Restorative Dentistry/Occlusion Dental Materials Anterior Esthetic Techniques and Materials Restoration of the Worn Dentition Thursday morning lecture Friday lecture Occlusion in Everyday Dentistry Update in Contemporary Restorative Dental Materials Thursday afternoon lecture Saturday lecture Fabricating Exquisite Anterior Provisionals Friday workshop Robert C. Fazio, DMD
Dennis G. Brave, DDS Kenneth A. Koch, DMD Periodontics Antibiotics and Dentistry Endodontics Friday morning lecture Changing Paradigms in Endodontic Therapy Medicine, Dentistry and Drugs Thursday lecture Friday afternoon lecture Changing Paradigms in Endodontic Therapy Workshop Periodontitis and Peri-Implantitis: The Good, the Bad Friday workshop and the Ugly Saturday lecture
Gerard J. Chiche, DDS Henry A. Gremillion, DDS
Cosmetic Occlusion Smile Design, Occusal and Esthetic Techniques Saturday lecture The Dynamics and Function of the Masticatory System: The Multiple (Inter)Faces of Occlusion Friday lecture Karen Davis, RDH, BSDH
Gerard Kugel, DMD, MS, PhD Dental Hygiene America’s Sweet Tooth Obsession and Its Impact on Oral and Esthetic Dentistry Systemic Health Saturday morning lecture The Do’s And Don’ts of Porcelain Laminate Veneers Thursday workshop Creating the Ultimate Doctor-Patient Hygiene Exam Saturday afternoon lecture Esthetic Dentistry: Materials and Techniques Update Friday lecture Special Event Exhibit Hall
CDA Presents will feature more than 550 Grand Opening exhibiting companies showcasing the latest in Thursday, 9:30 a.m. dental technology, products and services. Stay New Exhibit Hall Days and Hours ahead of the curve by exploring the innovative new products being launched in the exhibit hall. Thursday, May 3, 9:30 a.m.–5:30 p.m. Friday, May 4, 9:30 a.m.–5:30 p.m. Thursday–Saturday, Saturday, May 5, 9:30 a.m.–4:30 p.m. May 3–5, 2012
Visit cdapresents.com to maximize Family Hours your tradeshow experience. Daily, 9:30 a.m.– noon The Spot
This contemporary lounge in the exhibit hall features a Cool Product display, Net Café and charging station, a C.E. Pavilion, and an educational theater that is the venue for the Smart Dentist Series of free, one-hour lectures. Thursday
9:30–10:30 a.m. Nutrition (C.E.: none) Juli Kagan, RDH, MEd 11 a.m.–noon Establishing an Office Policy Handbook (C.E.: 20% – 1.0) Robyn Thomason Noon–1 p.m. Handling Refund Requests From Insurance Plans (C.E.: 20% – 1.0) Patti Cheesebrough 1–2 p.m. Nutrition (C.E.: none) Juli Kagan, RDH, MEd Friday
9:30–10:30 a.m. Yogernomics (C.E.: 20% – 1.0) Juli Kagan, RDH, MEd 11 a.m.–noon Patient and Parent Communication (C.E.: 20% – 1.0) Katie Fornelli Noon–1 p.m. Managing Patient Conflicts (C.E.: 20% – 1.0) Brooke Kozak 1–2 p.m. Yogernomics (C.E.: 20% – 1.0) Juli Kagan, RDH, MEd 4–5:30 p.m. Wine Seminar (Ticket Required)
Saturday
9:30–10:30 a.m. Staff Building (C.E.: 20% – 1.0) Art Wiederman, CPA Join us for interactive wine activities and trivia. You’ll learn to distinguish the various scents and 11 a.m.–12:30 p.m. Making the Best Decisions for flavors in wine by tasting both white and red Your Practice (C.E.: 20% – 1.5) William Van Dyk, DDS varietals and about pairings with both cheese and chocolate. Plus, you’ll have the opportunity to put Reference On-Site Show Guide for updated program your knowledge to the test and win prizes! information. Registration Information
• Extended online registration will be available starting Three Ways to Register March 2, 2012. (Faxed and mailed registrations will not be accepted after March 1, 2012.) If you register online during Online: cdapresents.com this extended period, obtain your materials at Email Express (Best option) Receive immediate confirmation Pick-Up at the Anaheim Convention Center beginning at 6:30 a.m. on Thursday, May 3, 2012. Fax: 877.714.3184 • If you register an employee who is no longer attending, bring the badge of the person not attending to exchange Mail: CDA Presents on-site for a new badge at no charge. 1201 K St., 16th Floor Sacramento, CA 95814 • To ensure a seat for every ticket holder, courses will not be oversold. Registration Information • Refunds will be given if requested in writing and badges • Register at cdapresents.com to secure an immediate spot in and tickets are returned by March 28, 2012. your preferred workshop, required course or special event • CDA will process and mail your registration materials based on availability. A confirmation email will be sent at least two weeks prior to the meeting. If you do not upon completion of your registration. receive your materials within this time frame, please • Registration forms that are faxed or mailed to CDA will call CDA at 800.232.7645. If you have corrections, be processed in the order received and do not guarantee additions or changes, please notify CDA in writing an immediate spot in workshops or special events. Phone before March 28, 2012. registrations cannot be accepted. • CDA member dentists will be registered at no charge. • Dentists may register staff and guests, but not other dentists. Dentists may not register under any category except dentist, and nonmembers must be identified. Membership dues must be paid for the current year to register as a member. • Special $75 registration fee for California nonmembers: Nonmembers can save $815 on registration by taking advantage of a special $75 one-time meeting registration fee. If you are already a member, tell your nonmember col- leagues about this limited offer. Materials for this category will not be mailed in advance, but will be available on-site at the membership counter. If you have already taken ad- vantage of this special rate at either CDA Presents meeting, your fee will be the standard nonmember rate. If you had a membership in 2011, you are not eligible for the non- member $75 one-time registration fee for 2012. • Register by March 1, 2012, to have your materials mailed to you in advance. (Note: Badge mailing will begin early March for registrations completed prior to this time.) This excludes the one-time nonmember reduced rate. Reserved Seating
Get Your Guaranteed Seat for Limited Lectures
Due to the popularity of many lectures, CDA Presents is testing a new “reserved seating” option. How does it work? For just $10, you can guarantee yourself a seat at any of the lectures below. Please note: This program is strictly optional, and reserved seating is limited. Participants can still attend at no cost on a first-come, first-served basis.
Lectures with reserved seating are listed below. For more information and to purchase reserved seats, visit cdapresents. com. Reservation tickets are only available in advance. No onsite sales.
General Information Receive your seat in these popular • All courses have limited seating. lectures for $10. • Some courses do not provide C.E. units. Thursday, May 3 • No videotaping, photography or audio recording with Lee Ann Brady, DMD personal equipment is allowed. Anterior Esthetic Techniques and Materials (a.m.) • No speaker or product has any endorsement, official or Page 39, Event # 063 otherwise, from CDA, except CDA Endorsed Programs. Occlusion in Everyday Dentistry (p.m.) Page 39, Event # 064 Types of Classes Kirk Behrendt, Lectures Seven Breakthrough Steps to High Performance Teams Free nonticketed courses are available on a first-come, first- (full day) served basis. Preregistration is not needed for lectures. Please Page 38, Event # 065 arrive early to ensure you get a seat. Friday, May 4 Workshops Ticketed courses are available for purchase during Terence E. Donovan, DDS, preregistration as well as on-site, if space is still available. Restoration of the Worn Dentition (full day) Page 58, Event # 066 Express Lectures Lectures that feature up-and-coming speakers who are new Tieraona Low Dog, MD. to CDA Presents. Be among the first to hear them! These Nutrition for the Dental Team (a.m.) speakers have not yet been scouted by the Board of Managers Page 64, Event # 067 and have accepted the invitation to present and be scouted at Life in the Balance: Strategies for Optimal Health (p.m.) this meeting without an honorarium. Page 64, Event # 068
Corporate Forums Saturday, May 5 Corporate-sponsored courses that may or may not be ticketed. Gerard J. Chiche, DDS, Smile Design, Occlusal and Esthetic Techniques (full day) Page 73, Event # 069 Ticket Details • Seat will be held up to 15 minutes after the program begins. • Seat will be released if the room is full 15 minutes after the start of the program. • Ticket must be presented at the door. • Please treat the ticket like cash — It is nonreplaceable. introduction
cda journal, vol 40, nº 1
CDA Research kerry k. carney, dds
The January and March issues of the Journal of the California Dental Association focus on several of the key studies that helped to shape the recommendations made in the three-phase access proposal that was passed by the 2011 CDA House of Delegates.
author Central to the access proposal is the economics of a dental therapist (New Zea- need to develop a dental public health land model), a dental health aide therapist Kerry K. Carney, dds, is infrastructure in California. The benefits of (Alaska native model), and the advanced editor-in-chief of the Journal of the California this are detailed in “California’s State Oral dental hygiene practitioner (ADHA pro- Dental Association. Health Infrastructure: Opportunities for posed model). Hers is a comprehensive Improvement and Funding,” by Joel Diring- economic analysis of proposed new dental er, JD, MPH, and Kathy R. Phipps, DrPH, team members. She considers the length RDH. Diringer and Phipps document lost and costs of education, the resulting debt opportunities in California and lessons burden, costs to set up practice and likely learned from states with successful state revenue generated from care provided. oral health programs. They make a compel- This issue of the Journal includes a ling argument that sustainable changes to comprehensive literature review on the oral health programs must be supported safety and quality of irreversible dental at the highest levels of state government. procedures performed by nondentist Paul Glassman, DDS, MA, MBA, providers worldwide. Ananda Dasanayake, provides a comprehensive exploration of BDS, MPH, PhD, examined the question dental residency programs in “Advanced “Are the irreversible procedures performed Dental Education Programs: Status and Im- by any auxiliary provider category safe plications for Access to Care in California.” compared to the same procedures per- He describes the history, funding, oppor- formed by dentists?” This first-of-its-kind tunities, and challenges of advanced dental research revealed there is insufficient evi- education programs for general dentists. dence to accurately answer this question. In “Economic Feasibility of Alternative Publishing these proprietary studies Practitioners for Provision of Dental Care provides CDA members and the profes- to the Underserved,” Anne Matthieson, sion with easy access to primary sources MHA, MBA, evaluates the comparative and essential information.
january 2012 29 Typical Patient I just don’t get how I have new cavities after spending all that money on fillings. Did we fix it?
So even diet soda is a risk factor? I guess that makes sense. What else can I do to keep lowering my risk? CariFree Patient
Change the conversation. It’s amazing how a 3–5 minute risk assessment can change who is accountable. What a relief.
CRA FORM Due to new research on cavities and what causes them, we are moving to treatment. Please fill out Name: ______professional during your appointment today. the “Patient Use ______Date: ______” section of this form ward a standard of care that can offer earlier detectio Rev 4 Questions about the information to the on best this of your ability. These items will be discus Would you like a free
determine if you have the bacterial infection that screening causes cavities? test today form? See the back for sed with yourn and dental to If diagnosed at risk for cavities today, would you be Q&A interested in discussing treatment options? . If needed, no habits? are you willing to modify your
yes RISK FACTORS no dietary
USE I notice plaque build maybe Not an option I take medications daily.-up (#______) on my teeth. I could, but yes Schedule a CAMBRA Start Webinar don I drink things other than milk, tea, or water ’t want to 2 times daily (other than with meals). Sure
PATIENT I like to snack 1 no more than -3 times daily between meals. no Do any of these other health concerns apply to you? yes (check all that apply) no and learn how to get the diagnostic yes Frequent tobacco use yes Acid reflux no Other drug use Diabetes Bulimia Do you yes suffer from Sjogren Do you have dry mouth at any time of the day? no CariScreen Testing Meter free.* ’s Syndrome any oral appliances present? yes
BIOFILM no CHALLENGE CariScreen Bacterial Assessment no yes DISEASE INDIC yes ATORS Visible Cavitations low Radiographic Lesions <1500 Sign up at start.carifree.com White Spot Lesions high > Cavity in Last 3 Years 1501 no
no ASSESSMENT SUMMARY yes no Biofilm Challenge yes Disease Indicators no and enter webinar code yes Risk Factors yes DIAGNOS low CLINICIAN USE ONLY L IS H Transfer information above to boxes below to determineno risk. Biofilm high N Challenge L H Y no $2,500
Biofilm yes Disease Indicators N Y Challenge L H CDA January. Risk Factors yes
Biofilm Disease Indicators N Y Challenge L H LOW RISK Risk Factors Disease Indicators Biofilm L MODERATE RISK N Y Challenge H Risk Factors 1 Disease Indicators Biofilm MODERATE RISK N Y Challenge Risk Factors 2 Disease Indicators HIGH RISK Risk Factors 3 HIGH/EXTREME RISK FREE 4 5
* CariScreen meter free with purchase of CAMBRA Start Package
10692 CAM CDA 0112Ad.indd 1 11/14/11 2:47:11 PM review: public health
cda journal, vol 40, nº 1
California’s State Oral Health Infrastructure: Opportunities for Improvement and Funding
joel diringer, jd, mph, and kathy r. phipps, drph, rdh
abstract California has virtually no statewide dental public health infrastructure leaving the state without leadership, a surveillance program, an oral health plan, oral health promotion and disease prevention programs, and federal funding. Based on a literature review and interviews with 15 oral health officials nationally, the paper recommends hiring a state dental director with public health experience, developing a state oral health plan, and seeking federal and private funding to support an office of oral health.
authors
Joel Diringer, jd, mph, is Kathy Phipps, drph, rdh, alifornia has virtually no Methodology the founder of Diringer is a California-based statewide dental public health This article is based on a literature and Associates, a health oral epidemiologist with infrastructure. The state has no review of documents relevant to state policy consulting firm considerable experience based in central California, in community-based dental director, no oral health oral health infrastructure and funding, specializing in oral health oral health research and plan, no statewide oral health as well as semistructured key informant and access to care. surveillance working with Csurveillance system and no statewide interviews conducted in 2010 with 15 national organizations and prevention programs. Dental services for experts on state oral health infrastruc- tribal organizations. low-income adults are limited to emergen- ture including federal officials in Health cy-type procedures and most children on Resources and Services Administration Medi-Cal do not have regular dental visits. (HRSA) and the Centers for Disease Con- The lack of leadership within California’s trol and Prevention (CDC), seven state state government means the state forgoes dental directors, a national oral health necessary funding for oral health and organization, and California stakeholders. preventive programs are not implemented. This article is intended to review the California’s Oral Health Crisis dental public health infrastructure in Cali- California’s oral health programs have fornia and other states, identify potential been decimated in recent years. In 2009, funding sources for oral health activi- the Legislature eliminated all but emer- ties in California, and provide recom- gency-related dental benefits for adults mendations for policies to be adopted in in the Medi-Cal program. Similarly, the California to ensure it has a viable infra- Legislature “indefinitely suspended” fund- structure that can develop, support, fund, ing for the California Children’s Dental and coordinate oral health programs. Disease Prevention Program (CCDDPP)
january 2012 31 review: public health
cda journal, vol 40, nº 1
that provided screening, oral health edu- The 2000 ASTDD report, “Building implement population-based preven- cation, fluoride applications and seal- Infrastructure and Capacity in State tion interventions; build community ants serving more than 300,000 school and Territorial Oral Health Programs,” capacity to implement community-level and preschool children in 32 counties. identifies elements that would build interventions; develop health systems n Fewer than one in five (19 percent) capacity for state oral health programs interventions to facilitate quality dental of California children aged 0-5 on to achieve the Healthy People Oral care services; and leverage resources to Medi-Cal had a dental visit in 2007. Health Objectives.7 The report speci- adequately fund public health functions.8 Benefits have now been eliminated for fies that a key infrastructure element is The CDC’s Division of Oral Health nearly all adult services under Medi-Cal.1 having leadership to address oral health has used ASTDD’s expertise to establish n More than seven in 10 (71 percent) problems, with a full-time state den- national standards for its funding and California children suffer from tooth decay tal director and an adequately staffed technical assistance to help state health by the time they reach the third grade.2 oral health unit with competence to agencies develop and operate public n Nationally, tooth decay is the most perform core public health functions. health programs to improve oral health. common chronic disease among children, The CDC has developed a collection five times more common than asthma.3 of tools for state health officials to plan, n Despite having 14 percent of the despite having develop, implement and evaluate oral nation’s dentists and 12 percent of the 14 percent of the nation’s health programs that include health nation’s population, California has 21 promotion and disease prevention.9 percent of the 4,230 federally designated dentists and 12 percent of Among other things, these resources dental health professional shortage areas.4 the nation’s population, include tools for developing a strong state These shortage areas are found throughout program infrastructure to ensure success- California, in both urban and rural areas. California has 21 percent of ful oral health programs. How California n Fewer than six in 10 (59 percent) of the 4,230 federally designated infrastructure measures up to CDC’s California residents received fluoridated components is contained in table 1. water as of 2008.5 dental health professional The importance of state oral health While California is still under the shortage areas. infrastructure is endorsed by the Insti- national average for fluoridation, this is a tute of Medicine in its recent report, major improvement over prior years. “Improving Access to Oral Health Care With the implementation of fluoridation ASTDD further describes the role of for Vulnerable and Underserved Popula- in the San Diego area in 2011, an estimat- a state oral health program as providing tions,” where it recommended that the ed 62 percent of Californians have leadership and programming to improve federal health care agencies “ensure that fluoridated water.6 oral health through the public health core each state has the infrastructure and functions of assessment, policy develop- support necessary to perform core dental National Standards for State Oral ment, and assurance. The assessment public health functions (e.g., assessment, Health Infrastructure role is fulfilled through a state-based oral policy development, and assurance).”10 After years of analysis and refine- health surveillance system. The policy ment, the characteristics of efficient development role is to provide leader- California’s State Oral Health and effective state oral health infra- ship to address oral health problems Infrastructure structures have been well-defined with a full-time state dental director, California Health and Safety Code by national organizations, including developing a state oral health plan and Section 104750 requires the Department of the Association of State and Ter- promoting policies for better oral health Public Health to maintain a dental program ritorial Dental Directors (ASTDD) and health systems. The assurance role is whose role includes, but is not limited to: and the CDC. These guidelines pro- to provide communications and educa- 1) Development of comprehensive vide an excellent roadmap of where tion to the public and policy-makers, dental health plans within the frame- California’s oral health infrastructure build linkages with coalitions, commit- work of the state plan for health to should be and how to get there. tees and workgroups; coordinate and maximize utilization of all resources;
32 january 2012 cda journal, vol 40, nº 1
table 1
H ow California Measures up Against CDC’s Elements for State Oral Health Infrastructure
1. Leadership capacity No dental director with dental or public CDC recommends a full-time dental health experience, or minimum staff capacity 2) Provide the consultation nec- director who is an oral health professional essary to coordinate federal, state, with training in public health and other county, and city agency programs professional staff. concerned with dental health; 3) Encourage, support, and augment the 2. Data collection and surveillance Needs assessment last done in 2004-2005 CDC recommends the development of a for children by Center for Oral Health and efforts of city and county health depart- funded by private and federal funders. ments in the implementation of a dental dedicated oral health surveillance system which measures key oral health indicators System for California Oral Health Reporting health component in their program plans; (e.g., fluoridation status, caries experience, (SCOHR) was developed by the San Joaquin 4) Provide evaluation of these pro- and complete tooth loss) using standard and County Office of Education to compile state- grams in terms of preventive services; and comparable approaches. wide data for AB 1433 – the kindergarten dental check-up law implemented in 2007. 5) Provide consultation and pro- gram information to the health profes- 3. State oral health plan None sions, health professional educational CDC recommends a state oral health plan institutions, and volunteer agencies. to include specific objectives related to oral Section 104755 mandates that the health promotion, disease prevention and dental program be administered by a control, and specific risk factors. licensed dentist. 4. Statewide oral health coalition Oral Health Access Coalition (OHAC) is Compliance with the legislative CDC recommends the formation of an administered by Center for Oral Health requirements of sections 104750 and active, independent statewide oral health and California Primary Care Association 104755 appears to be minimal. There coalition with diverse representation and has been no state dental director for the help formulate plans, guide program activities, and seek funding. dental program for 15 years. The oral health unit’s “chief” and sole staff person 5. Policy development None from the State Department of is not a dental professional. There is no CDC recommends that the state oral health Public Health state oral health plan nor is there any program conduct a periodic assessment of evaluation of programs. Moreover, there laws, regulations, administrative policies, and is no capacity to provide consultation systems-level strategies that have the poten- and support to local health jurisdic- tial to reduce oral diseases. tions, health professions, or educational 6. Evaluation of oral health programs No overall evaluation plan institutions. There is also a lack of ability CDC recommends expert assistance in plan- to apply for and manage federal and other ning and conducting an evaluation of the state grant programs to support oral health. oral health program can assist in determining if its goals and objectives are being met. Available Federal Funding and Support Most states with comprehensive 7. Community water fluoridation program There are state water fluoridation consultants paid for with federal grants, as oral health programs rely heavily on CDC establishes guidelines for a state water fluoridation program to promote, implement, well as a fluoridation council administered by federal funding to support their pro- and maintain consistency of community water the California Dental Association Foundation. grams and use minimal state funds. The fluoridation efforts. two major sources of state oral health funding from the federal government 8. School-based dental sealant program Suspended indefinitely are the CDC and HRSA, which includes CDC recommends school-based dental Maternal and Child Health block grant sealant programs that are highly effective funds. In addition, some states finance programs to prevent tooth decay in children targeting vulnerable populations that may be their oral health programs using match- at greater risk of developing decay and have ing federal Medicaid (Medi-Cal) funds. difficulty in accessing care. The national health reform legislation —
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cda journal, vol 40, nº 1
the Patient Protection and Affordable Care Visibility in State Agency Is Critical Doing Something Is Better Than Act (PPACA) — significantly expands feder- A state oral health office must have suf- Doing Nothing al funding for oral health. It expands CDC’s ficient visibility in the state health depart- It took a number of years for the funding for cooperative agreements for oral ment to be considered a core component successful programs to develop. Rather health infrastructure from the current 16 of the health infrastructure and depart- than trying to plan and implement all states to all states. It also expands funding ment funding. Access to department components at one time, the directors for school-based sealant programs to all 50 heads and policy-makers is key to develop- developed the programs over time. Hav- states. These funds must be requested by ing and implementing strategic agendas. ing a strong leader, developing an oral a state, and only state agencies can be the health plan in partnership with state- recipient of these funds. These funds have State Legislation Establishing an Office of wide coalitions, and accessing available been authorized but not as yet appropriated. Oral Health and Director Position Is Helpful funding are important first steps. In addition to its funding through but Not Essential cooperative agreements, the CDC has also Many states have codified the role Funding Lessons provided staff directly to states. These staff of the office of oral health and mini- members from the public health service mum qualifications of a dental director. The First Reason for Not Getting a Grant have been assigned to act as dental directors However, some states with strong oral Is Not Applying or subject matter experts for a period of health offices do not have any legisla- The federal government has had funds time. Often, these staff assist the state in ap- tive mandate for an office of oral health. available to support state oral health plying for additional federal funding to fur- Having a legislative mandate however, infrastructures for many years, but Cali- ther develop programs and infrastructure. does not guarantee an effective office. fornia has not applied. California should begin applying now for CDC infrastruc- Lessons From the States Key Development Lessons ture funds and strongly consider applying A number of lessons were learned for additional HRSA funds. If the state from interviews with state and federal Models and Infrastructure Support Are does not currently have the capacity to officials that are relevant to California. Readily Available From CDC and ASTDD prepare a grant application, a number Some states have developed their oral of partners can assist in the effort. Key Elements in a State Program health offices from scratch with the support Structure of the CDC and ASTDD. These agencies have State Funding Is Not Key to an Effective national standards for offices of oral health, Oral Health Program Leadership, Leadership, Leadership tools and roadmaps for developing a strong A number of the state dental direc- The most critical element for an ef- infrastructure, funding, and technical assis- tors noted that they receive little or fective state oral health office identified tance. California could greatly benefit from no state funding for their programs. by the dental directors was leadership. the support and guidance of national orga- When state funds are allocated, they It is essential to have a person with an nizations to develop a strong office of oral are primarily used for core infrastruc- oral health background and public health health and effective oral health programs. ture, with other funds being leveraged orientation, and a vision for how to for programs. According to a national improve the oral health status in a state. Not All Work Needs to Be Done by the State survey of state oral health fund- The state dental directors emphasized ing conducted by the Pew Center on Strong Support From Department and that the state oral health office does not the States, 94 percent of funding for Policy-makers generally operate large programs, but California’s Oral Health Unit is state While it is essential to have a strong rather partners with other agencies in funding compared to many states director in the oral health office, it is also im- the public and private sectors to imple- where less than half of the funds come portant to have an understanding and sup- ment programs. The basic roles of the from the state. The current state fund- port of leadership in the state health depart- state office of oral health are assessment, ing is for one staff person to provide ment, as well those in policy-making roles policy-making, and assurance rather administrative support for the few in the executive and legislative branches. than actual administration of programs. contracts and grants that the state has.
34 january 2012 cda journal, vol 40, nº 1
Creativity and Flexibility in Grant Seeking Is Essential Effective dental directors bring together funding from various sources to support their offices and ensure that effective statewide oral health programs are in place. Many states rely heavily on Maternal and Child Health block grant funds and some use Medicaid match- ing funds to support their offices. State programs have also partnered with philanthropies to develop programs focused on vulnerable populations. Partnerships Coalitions and Partnerships at the Statewide and Local Levels, Both in and out of Government, Are Critical State oral health programs rely heavily on coalitions and partnerships to develop and implement their strategies. These partners include associations of dental professionals, educational institutions, dental plans, local health jurisdictions, health advocates and policy-makers. It is also important for oral health offices to develop strong relationships with other state departments such as Medicaid, Title V Maternal and Child Health programs, professional licensing, and education. Build on Successes and Existing Programs and Resources California is fortunate to have a wide array of programs and funders such as dental schools, engaged dental and dental hygienist associations, First 5 commissions, oral health advocacy groups, school-based programs, a state- wide oral health access coalition, and private philanthropies, and some local health department programs. Building on these programs and drawing from their experiences and resources will support the success of an oral health program.
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cda journal, vol 40, nº 1
Build Partnership and “Champion” Strategies Hire a Director With Dental Public Health Work With Existing Stakeholders and Developing and strengthening Experience Programs programs requires strategies for build- California needs to hire a dental director California has a myriad of statewide ing partnerships and champions. with public health experience. There has and local oral health coalitions and Having strong champions for oral been no dental director in California for programs. There are also national experts health on local and statewide levels more than 15 years despite the mandate of at California’s dental educational institu- is critical to garnering support from Health and Safety Code Section 104755. The tions and professional associations. The policy-makers and funding sources. The dental director needs to have the full sup- state’s oral health unit should maximize nurturing of these partnerships is an port of the department and policy-makers their inclusion in strategy development, essential part of successful programs. in developing and implementing an oral program implementation, and evaluation. health agenda in California. Without the The role of the office should be to ensure State Oral Health Plan and Evaluation leadership of a dental director and strong adequate funding for programs, but not support from policy-makers, it will not be necessarily to operate the programs itself. If You Don’t Know Where You Are Going, possible to develop an effective oral health You Won’t Know if You Are Getting There program in California and address the grow- Seek Federal and Private Funding to Having a comprehensive state ing oral health needs of the population. Support Programs oral health plan will guide program California has not taken advantage of development, grant seeking, and the millions of dollars of federal assistance funding allocation. It also enables having strong champions that is provided to states for oral health evaluation to measure the success for oral health on local infrastructure. With the expansion of fed- of programs and strategies. A com- eral assistance for oral health, California prehensive plan will also include and statewide levels is needs to immediately investigate federal strategies to ensure the public is critical to garnering support funding to support an office of oral health informed about oral health policy and the development and implementation and the direction the state is going. from policy-makers and of an oral health plan. In addition, Cali- funding sources. fornia should look to the experience of Data Can Drive Work and Highlight Successes other states that have used other available Building a surveillance system funds such as MCH block grants, Medic- that monitors and reports the burden Develop an Oral Health Plan Building on aid (Medi-Cal) funds, and philanthropy of oral disease with periodic updates What Exists Throughout California to support their offices of oral health. allows oral health programs to track California has no state oral health progress on key indicators, develop plan to guide policy-makers, state depart- Develop New Childhood Prevention Programs new strategies and highlight its suc- ments, local health jurisdictions, advocacy With the “indefinite suspension” of cesses to policy-makers and the pub- organizations, professional associations, the decades-old school-based Children’s lic. Having accurate data is critical to funders, educational institutions and Dental Disease Prevention Program, Cali- decision-making and garnering support community-based programs. Nor are there fornia has an opportunity to reinvigorate from partners and policy-makers. effective assessment tools to measure a school-based oral health program using progress in meeting oral health goals from the latest strategies and interventions, as Recommendations for California those programs in effect at the local level. well as seek new funding streams. Promis- for Building a State Oral Health The oral health plan needs to be built ing practices, such as using preschools, Infrastructure upon what exists, identify needs and gaps Head Start, and WIC sites to link very Based on the interviews with state in programs and develop strategies to fill young children and their parents to dental and national oral health infrastructure the gaps. It must be developed through a care and education, should be investi- experts and review of relevant literature, collaborative, inclusive process that brings gated. Services for older children through the following recommendations are made together California’s stakeholders and draws school-based preventive and treatment for California: upon in-state and out-of-state expertise. programs can also be expanded.
36 january 2012 cda journal, vol 40, nº 1
Conclusion that represent skill sets needed for a successful state oral health program, whether they are competencies promote California should not continue to identifying, leveraging and sharing of resources, and collabora- ignore its responsibility and the legislative tion with partners to maximize skill sets. astdd.org/docs/ mandate to have coordinated strategies to CompetenciesandLevelsforStateOralHealthProgramsfinal. pdf. Accessed Nov. 1, 2011. improve the oral health of its residents. 9. Centers for Disease Control and Prevention, Infrastructure The first step for overcoming the neglect development tools, March 2011. cdc.gov/oralhealth/state_pro- of the past decades is to appoint a dental grams/infrastructure/index.htm. Accessed Nov. 1, 2011. 10. Institute of Medicine and National Research Council, director to provide leadership in mapping Improving access to oral health care for vulnerable and under- out proven health improvement strate- served populations, July 2011. nap.edu/catalog.php?record_ gies. Far smaller states than California id=13116. Accessed Nov. 1, 2011. have received substantial federal support to fund this effort. The national health To request a printed copy of this article, please contact Joel Diringer, JD, MPH, Diringer and Associates, P.O. Box 14822, reform legislation makes additional oral San Luis Obispo, Calif., 93406. health funds available to states, but states need to have an adequate infrastruc- ture to apply for and administer these funds. Without leadership and support, Californians will continue to suffer with preventable dental disease, while other states receive federal funds to improve the health of their populations. references 1. California Health Care Foundation, Denti-Cal Facts and Figures. May 2010. www.chcf.org/publications/2010/05/ dentical-facts-and-figures. Accessed Nov. 1, 2011. 2. Dental Health Foundation (now Center for Oral Health). Mommy, it hurts to chew: the California smile survey — an assessment of California’s kindergarten and third-grade children. February 2006. centerfororalhealth.org/publications. Accessed Nov. 1, 2011. 3. U.S. Department of Health and Human Services, Oral health in America: a report of the surgeon general, May 2000. 4. U.S. Department of Health and Human Services, www. hpsafind.hrsa.gov. Accessed Nov. 1, 2011. 5. Centers for Disease Control, 2008 Water Fluoridation Statistics. cdc.gov/fluoridation/statistics/2008stats.htm. Accessed Nov. 1, 2011. 6. Time to review annual water quality reports, ADA News, June 6, 2011. ada.org/news/5923.aspx. Accessed Nov. 8, 2011. 7. Association of state and territorial dental directors (ASTDD), building infrastructure and capacity in state and territorial oral health programs, April 2000. astdd.org/docs/ Infrastructure.pdf. Accessed Nov. 1, 2011. 8. ASTDD has established additional guidelines and resources for effective state oral health programs. The guidelines for state and territorial oral health programs (updated June 2010) provides a framework for state and territorial oral health programs to implement the public health core functions and essential public health services to promote oral health. http://www.astdd.org/docs/ASTDD_GuidelinesfinaldraftSec- tionI6-4-101.pdf. ASTDD’s Competencies for State Oral Health Programs (Sep- tember 2009) describes 78 competencies in seven domains
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cda journal, vol 40, nº 1
Advanced Dental Education Programs: Status and Implications for Access to Care in California
paul glassman, dds, ma, mba
abstract Primary care residencies in dentistry include general practice residency and advanced education in general dentistry — collectively known as postdoctoral general — dentistry and pediatric dentistry. These primary care programs are the most likely to serve underserved populations during the training experience. An expansion of primary care dental residency positions in California has the potential to positively impact access to care in California. However, there are significant political and financial barriers to realizing this potential.
author rimary care residencies in den- tablished in the United States in the 1700s, tistry include general practice they were created to provide a labor force Paul Glassman, dds, ma, 1,2 mba, is a professor of residency (GPR), advanced educa- for hospital dispensaries. These infor- Dental Practice, Arthur tion in general dentistry (AEGD), mal hospital-based training sites became A. Dugoni School of collectively known as postdoctoral rotating internships or mixed programs in Dentistry, San Francisco. Pgeneral dentistry (PGD), and pediatric den- the middle of the 1900s. The first dental tistry (PED). These primary care programs specialty accreditation standards were represent the largest group of dental resi- adopted in 1963.3,4 In 1972, the American dencies, the fastest-growing, and the most Dental Association’s (ADA) Council on likely to serve underserved populations Dental Accreditation (CODA) officially during the training experience. They are also changed the name of the hospital–based the most likely to add new programs and internships to “residency” and issued ac- positions if the number of dental residency creditation requirements for GPR because positions were increased. For this reason, they perceived that the programs in exis- the history of dental residency education in tence at that time were not well-defined this paper and other topics in the paper will and not always of high quality.5,6 Since the focus on primary care dental residencies. GPR programs and their precursors had The first dental residency positions their origins in hospitals and offered all were started in the early 1900s. Like medi- the available PGD positions, the require- cal residency positions that were first es- ment that these programs be sponsored or
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cda journal, vol 40, nº 1
co-sponsored by a hospital was incorpo- ing care. This mechanism was adopted Expansion of Dental Residency rated into the accreditation requirements. because it provided strong incentives Positions: Financial Implications In the period from 1974 to 1982, a for hospitals to reduce costs. However, There are a number of variables number of nonhospital institutions the government realized that costs were that impact the financial implica- wanted to offer residency programs and higher in teaching hospitals than in non- tions of adding GME-supported dental began advocating to be able do so.5,7 The teaching hospitals so they added addi- residency positions. These include: result of these efforts was the develop- tional GME payments, based on resident n Variations in GME reimbursement ment of accreditation standards for count and the number of Medicare bed rates for hospitals; AEGD programs, thus allowing non- days for teaching hospitals. Subsequent n The required three-year phase-in of hospital institutions to sponsor PGD legislation allowed hospitals to support GME support; programs.8 Subsequent revisions to the dental residency positions in affiliated n Variations in “credit” received by AEGD and GPR accreditation standards outpatient sites and many dental schools hospital-based dental departments for have preserved the two accreditation began to develop affiliation agreements GME reimbursement; tracks although the necessity for this n Variations in negotiated agreements has been questioned.9 In January 1998, between nonhospital settings and the commission adopted a major revi- hospitals for reporting and sharing of sion of the accreditation standards for graduate medical GME reimbursement; and both AEGD and GPR programs.10 These education funding remains n Variations in production and standards became effective in January expenses of residents in different settings 2000. They incorporated competency a viable option for and institutions. concepts, were more flexible than previ- expansion of dental Hospitals are reimbursed for dental ous standards, promoted program in- residency positions through “direct” GME novation, and have similar language and residency programs and sites. payments (DME), which are supposed to structure throughout the AEGD and GPR cover the cost of resident’s stipend, ben- standards. This change was illustrative of efits, and certain teaching costs. They also the strong links and overlapping struc- receive “indirect” GME payments (IME), ture and goals between these programs. with hospitals to obtain GME support which are supposed to cover hospital over- A subsequent revision of the AEGD for their dental residency positions. head for having residents such as costs for and GPR standards in 2007 retained In 2003, the U.S. Center for Medicare the medical education office staff, hospital the parallel language and structure.11 and Medicaid Services (CMS) restricted administrations, and similar expenses. the use of this GME support to the The amount of total GME support for Expansion of Dental Residency formation of “new” programs. Schools residency positions varies tremendously Positions: Graduate Medical Education that had developed affiliation agreements from hospital to hospital. Some hospitals Funding with hospitals to support pre-existing report total GME reimbursement rates of The federal government has supported programs were no longer eligible to $25,000 per resident. If they are paying teaching hospitals through graduate receive this funding. This change and stipends in that range or above, there is no medical education (GME) funding since other restrictions on the use of GME direct financial benefit, at least in terms of the 1970s. At that time, a major change funding (such as a three-year phase in GME reimbursement versus direct costs, was made in the funding mechanism for for funding) has reduced the number of to the hospital for adding a dental resi- Medicare hospital stays from a cost-based hospitals and schools willing to de- dent. Other hospitals receive total GME reimbursement mechanism to a payment velop new programs and add positions. reimbursement close to or more than mechanism based on diagnostic-related In spite of these developments, some $100,000 per resident. For these hospitals groups (DRG). The DRG system reim- hospitals have continued to expand and adding a dental resident is a clear finan- bursed hospitals based on the diagnosis develop new programs. GME funding cial benefit, even without counting any of the patient’s condition irrespective remains a viable option for expansion income from patient care or other resident of the length of stay or costs of provid- of dental residency programs and sites. activities. The result of all these factors is
40 january 2012 cda journal, vol 40, nº 1
that some hospitals lose money by add- impacted revenue for dental residents a real delivery system. In short, they are ing dental residency positions and some who were treating a significant number “faster” and this translates into higher make a profit for every position added. of patients with Denti-Cal coverage. production in the remainder of their Another factor in a hospital’s decision GME-supported dental programs dental school career. Second, many dental to add dental residents is the three- outside of hospitals are permitted and school clinics are overcrowded with stu- year phase-in for GME payments. This can be located in dental schools and dents waiting in line for chairs or instruc- mechanism is referred to as the “three- community health centers. The hospi- tors. Having a segment of the student year rolling average.” Hospitals receive tal can count residents placed in these body out of the clinic each day relieves payments in arrears so the effect is that sites on the hospital’s resident count if some of this congestion and increases the they receive no money in the first year, an appropriate affiliation agreement is productivity of the students who remain one-third of their eventual payment developed with the affiliated site. There at the school. Finally, dental schools all amount after the second year, two-thirds are many nonhospital sites that have subsidize their clinic operations with after the third year, and full payment only developed affiliation agreements with other revenue. They lose money on every after the fourth year. This means that dental chair they operate. Many schools even hospitals that will eventually realize that have created new clinics or remod- excess revenue over expenses from GME eled their clinics in the last several years payments for dental residents must be dental students have chosen to build smaller clinics, willing to invest in subsidizing these posi- return from community reduce clinic operating expenses, and tions for several years before they begin increase rotations to community sites. to receive net income from adding these rotations with better The California Dental Pipeline Pro- positions. Even those hospitals with high skills in working in a real gram, funded by The California Endow- GME reimbursement rates may not want ment, and the National Dental Pipeline to make the initial investment or take on delivery system. Program, funded by the Robert Wood another program, especially with the un- Johnson Foundation, supported a large certainty about long term CMS support. increase in the last decade in the time In addition, some hospitals do not dental students and residents spend in give the hospital dental department hospitals and do receive GME-based community sites during their educational “credit” for the revenue received by the payments from the hospital. These sites programs. During this time, data has hospital for the dental residents. The include many dental schools. However, been collected about the financial impact dental department may be presented the arrangements and payment structure of these experiences on dental schools with a budget that reflects the salary is extremely variable. Even though the and community rotations sites. Like and other costs for having residents hospital is obligated to cover the resi- other factors described here, the results while the CME payment to the hospital dent’s stipend and benefits and certain have been variable. The results varied that pays for those costs is assigned to teaching costs, some hospitals require from reports that they “just break even other areas in the hospital’s budget. the affiliated institution to share some compared to not having the students or Finally, the financial impact of add- “clinic revenue” or develop other charges residents” to the conclusion that both ing dental residents depends on the that effectively reduce the payments students and residents significantly revenue generated by the residents and received by the affiliated institution. increase the revenue of the CHC. the associated expenses. Variations in Those dental schools that have tracked In one federally qualified health patient population, payer mix, physical the impact of dental student or resident center (FQHC) the dental director facilities, dental staff, and other factors rotations on the school’s income and reported that the faculty dentists spent can produce widely differing revenue and expenses have generally found the results so much time supervising dental stu- expenses from resident’s efforts from to be positive. There are several factors dents and residents that any income hospital to hospital. The elimination of that contribute to this outcome. First, generated by the residents was offset by most dental benefits for adults under dental students return from community equivalent decreased income from the the Denti-Cal system in July 2009 has rotations with better skills in working in faculty dentists. Analysis of financial
january 2012 41 dental care residencies
cda journal, vol 40, nº 1
table 1
National Advanced Education Programs and Dental School Graduates: 2009-10
advanced education programs # % data at another FQHC found that dental students and dental residents added Specialty 439 61% about $1,000/day to the clinic’s income.12 PGD 285 39% Clearly, the two clinics described here Total 724 handled the scheduling and supervision of dental students and residents differ- advanced education 1st year enrollment ently. Some of this variation is related # % to physical and local circumstances and Specialty 1,543 49% some related to educational philosophy. The conclusion is that specific operational PGD 1,609 51% and educational arrangements are critical Total 3,152 to determining the financial impact of dental students’ and residents’ presence dental school graduates in community clinics. The same holds for Graduates 4,873 the impact of adding resident positions to dental schools or hospital clinics. Available Positions 3,152 65%
Expansion of Dental Residency Positions: National Calls for Expansion ate education as condition of licensure.15 implementing universal dental residency Postdoctoral education became manda- Again in 1995, the Pew Commission rec- training in order to accelerate system tory for licensure in medicine in the 1940s, ommended the creation of postgraduate changes that will better serve the public’s driven by the need for hospitals to have a education opportunities for all graduat- interests.20 Finally, in 2011, the Institute stable and low cost in-hospital workforce.1 ing dentists.16 In 1995, the Institute of of Medicine (IOM) recommended that Although hospital financial consider- Medicine suggested that postdoctoral HRSA should dedicate Title VII funding ations do not play a role in dentistry, programs be expanded over five years to to support and expand opportunities there has, nevertheless, been discussion accommodate every dental graduate.17 for dental residencies in community- about expanding the role of postdoctoral In 2002, the executive summary of based settings and subsequently, state education in dentistry for many years. the American Dental Association’s future legislatures should require a minimum In the last 30 years, numerous of dentistry report stated that “when of one year of dental residency before national commissions have called for economically and logistically feasible, a a dentist can be licensed to practice.21 expanded or required postdoctoral educa- PGY-1 year should be a requirement for all The thrust of many the national reports tion for dental graduates. In 1983, the dental graduates.”18 In 2003, the American listed above has been the need for further American Dental Association Strategic Dental Education Association called for education of dental graduates in order Plan for Dentistry recommended there dental schools to encourage graduates to to be prepared to treat an increasingly be a requirement that all graduates take a pursue a year of service and learning that complex patient population and to become year of postdoctoral training.13 In 1992, the would not only make the students more competent in the increasingly complex American Association of Dental Schools competent to provide increasingly com- field of dentistry. Another phenomenon formed a postdoctoral year 1 (PGY-1) plex care, but also serve to improve access that has paralleled these discussions is the Commission that recommended increas- to oral health care, and called on ADEA to attention that state legislatures and policy- ing opportunities for postdoctoral educa- work with other organizations to advocate makers have given to the issue of lack of tion in order to create a PGY-1 position for for a requirement that all dental gradu- dental care for underserved populations. every dental school graduate who wants ates participate in a year of service and In order to address the increasingly visible one.14 In 1993, the Pew Commission called learning in an accredited PGY-1 program.19 inability of underserved populations to for the integration of all phases of dental In 2005, HRSA recommended develop- obtain oral health services a number of education and a mandate for postgradu- ing and supporting a national strategy for organizations and states have passed or
42 january 2012 cda journal, vol 40, nº 1
5,000
4,000 Predoc PGD 3,000
ositions Specialty
2,000
N umber of P 1,000
0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Year figure 1. Comparison of dental school graduates with specialty and PGD first-year enrollment. are considering measures that would bring tional mandate to require postdoctoral ate year of training can improve access foreign dentists to the state, revamp licen- training to obtain a dental license, several to care.24 That evidence plus consider- sure requirements to encourage or require states have adopted regulations with this ations of the educational benefits are postdoctoral education, expand the role of requirement. Delaware has for many years listed as justification for the recom- allied dental personnel, and enlist nonden- required completion of an accredited mendation to create a required year of tal personnel in providing oral health care. residency program in order to be eligible residency education prior to licensure. to take the state licensure examination. Required Postdoctoral Education In 2002, New York adopted legislation Current Status of Postdoctoral There are numerous private and gov- that allows dental school graduates to Education in Dentistry ernmental initiatives that are taking place substitute completion of the first year to increase availability of oral health care an accredited residency program (PGY-1) National Data for underserved populations. However, for the clinical portion of the licensure The American Dental Association many of these have had, and are predicted examination. Several other states have publishes a Survey of Advanced Dental to have, very minor effects. In one analy- adopted similar regulations including Education. The latest survey available sis, the Center for California Health Work- Washington, Minnesota, and California. contains data from the 2009-10 academic force Studies at the University of Califor- In California, this exemption applied year.23 That publication lists the num- nia, San Francisco, compared all of the only to graduates of PGD programs. In ber of accredited advanced education strategies for increasing provider work- 2007, New York changed its regulations to programs and enrollment and trends force for underserved populations in Cali- require the completion of an accredited from 2005-06 to 2009-10 and other fornia, including the impact of required PGY-1 year in order to obtain a licensure data over the last decade. This data is residency education. They concluded that in that state. As of that date there was no summarized in table 1 and figure 1. the strategy with the largest potential for requirement to take a licensure examina- There are several items to note in increasing oral health services to under- tion nor was passing a licensure examina- the survey results, some of which are served populations was the requirement tion a part of the process for obtaining illustrated in table 1 and figure 1: for a required year of “service and learn- a license to practice in New York. 1. PGD education includes dental ing” in an accredited residency program.22 The 2011 IOM report specifically cites anesthesiology and oral medicine. Although there has not been a na- the evidence that a mandatory postgradu- However, these programs were only
january 2012 43
dental care residencies
cda journal, vol 40, nº 1
table 2
California Advanced Education Programs and Dental School Graduates: 2009-10
advanced education programs recently accredited and constitute 2009-10 2009-10 % very few programs and positions. 2. PGD programs tend to be larger Specialty 38 62% than specialty education programs. In PGD 23 38% the 2009-10 academic year, specialty Total 61 education constituted 61 percent of advanced education 1st year enrollment programs but only 49 percent of first- year enrollments. It should be noted that 2009-10 2009-10% for the purpose of this paper, first-year Specialty 140 52% enrollment is the best predictor of the PGD 131 48% number of future practitioners with a Total 271 particular educational background. dental school graduates 3. The total number of first-year posi- tions in accredited advanced education Graduates 641 programs has risen from 2,581 in 1999 to Available Positions 271 42% 3,152 in 2009, an increase of 571 posi- tions. However, during the same period, the number of dental school graduates California positions for 42 percent of sociation, and the California Primary Care has increased from 4,095 to 4,873, an the California dental school graduates. Association and funded by The California increase of 778. While the percent of This data is summarized in table 2. Endowment — developed a plan to have accredited advanced education positions The number advanced education the dental schools form a consortium available for dental schools graduates positions available in California for to negotiate with one or more hospital has remained constant over the last dental school graduates is lower than to provide GME support for a combined decade, varying between 63 percent and the national average with there be- California program. However, the major- 65 percent, the gap between the number ing enough positions in California for ity of dental schools did not want to par- of graduates and the number of positions 42 percent of graduates and enough ticipate in a program that was not “their is wider today than it was a decade ago. positions for 65 percent of graduates own program.” One recent activity that nationally. While a number of Califor- should be noted is an increase in the num- California Data nia graduates seek advanced education ber of programs and positions affiliated In California, as of the 2009-10 aca- positions in other states there are also with the Lutheran Medical Center (LMC) demic year, the ADA survey lists 35 total graduates from other states seeking in Brooklyn. LMC is the institution in the accredited advanced education programs positions in California. In any case, United States that has developed the most offered in dental schools with 30 being there is a net shortage of positions for widespread network of affiliated residency specialty and five being PGD programs. California graduates. The results of sites supported by GME funding. LMC In nondental school settings there were previous surveys and informal discus- uses distance education technology to 19 institutions offering a total of 26 sions have indicated that only about support the didactic portion of its affili- accredited advanced education pro- 50 percent of California dental school ated programs and develops affiliation grams with eight being specialty and 18 graduates pursue advanced education agreements with community health cen- being PGD programs. Combined dental compared to more than 90 percent of ters for the clinical training of residents. school and nondental school programs graduates at many East coast schools. As of the 2010-11 academic year, LMC has in California include 61 total programs There have been several initiatives about 10 affiliated sites in California host- with 38 being specialty and 23 being to increase the number of available ac- ing about 15 LMC PGD residents.24 LMC PGD programs. In these programs the credited advanced education positions is in discussion with a number of other first year enrollment is 131 for PDG pro- in California. The California Pipeline community health centers and plans to grams and 140 for specialty programs. Program — a collaboration of California continue to increase the number of af- This means that there are enough dental schools, the California Dental As- filiated sites and programs in the state.
44 january 2012 cda journal, vol 40, nº 1
Federal Support for Primary Care The other potential impact on ad- with the largest potential for increas- Dental Residency Programs and vanced dental education in health care ing oral health services to underserved Health Reform reform is a large increase in the number populations was the requirement for a In addition to GME support de- of people eligible for Medicaid benefits required year of “service and learning” scribed earlier, the federal government and a continuation of the decade-long in an accredited residency program.22 has supported the expansion of primary expansion of community health cen- 3. There has been considerable care dental residency positions since ters. To the extent this increase includes speculation about the impact that the 1978. Handelman reviewed the federal expansion of children eligible for Denti- requirement in New York for comple- grant support for advanced training Cal services and an expansion of CHC tion of an accredited residency program in general dentistry from the 1970s to dental departments, there could be a large in order to receive a New York dental 1990s, which began with the Health increase in the need for dental providers license would have on graduates behavior Professions Educational Act of 1976.5 willing to accept Denti-Cal for payment and access to care issues. Discussions by The original and continuing purpose and willing to work in the CHC system. the author of this paper with program of the federal grant program was to directors in New York do not reveal much increase the number of training posi- change in the number of applicants to tions in PGD programs. There was the the expansion of residency programs. In fact, they report perception that overspecialization was dental residency positions a decrease in the number of applicants an increasing problem in dentistry, as in for licensure in New York. There are far medicine, and that the federal govern- has been proposed as too many variables involved to separate ment should support primary care one part of a strategy to the impact of New York’s educational initiatives that would expand the skills requirement from other factors, but it of the general dentist and reduce reliance improve the oral health of should be noted that prior to the enact- on specialists. Between 1978 and 1990, underserved populations. ment of this requirement New York had the government invested almost $40 a high rate (around 90 percent) of dental million in funding the development and school graduates attending advanced expansion of PGD programs. Since that education programs. Thus, there was time, Title VII funding has continued Implications of Dental Residency little room for an increase in that area. with various federal administrations Education for Access to Care 4. Informal conversations between the increasing or decreasing the amount of The expansion of dental residency posi- author of this paper and directors of com- funding. In the 1990s, pediatric dental tions has been proposed as one part of a munity health center (CHC) dental depart- residency programs were added to the strategy to improve the oral health of under- ments affiliated with the Lutheran Medical list of primary care programs eligible served populations. It is difficult to quantify Center revealed CHC dental directors feel for funding under this mechanism. how much benefit would be derived from that having a dental resident at their site The most significant provision of an expansion of the number of programs has allowed them to increase the number of recently enacted health care reform or positions. Some items to note include: services they provide. Some health centers legislation related to the subject of this 1. A 2002 analysis of the impact of have experienced a large increase in the paper is a renewed and increased com- PGD training on practice patterns of number of services provided and the num- mitment to fund expansion of primary program graduates concluded that PGD ber of patient’s served after adding resi- care residency programs. The legislation training has an enduring impact on dency positions to the dental department.12 establishes a unique appropriations line practice patterns and improves access to item for training of general, pediatric, dental care for underserved populations.26 Opportunities and Challenges in and public health dentists and appro- 2. As described earlier, a comparison Expanding Accredited Advanced priates $30 million for fiscal year 2010 of various workforce strategies by the Education Programs in California to train oral health workforce (Note: Center for California Health Workforce There are a number of available Currently, dental and medical training is Studies at the University of California, opportunities and challenges to over- appropriated in a single, lump sum).25 San Francisco, concluded that the strategy come in expanding accredited advanced
january 2012 45 dental care residencies
cda journal, vol 40, nº 1
education programs in California. residency positions. The cost of this ex- There will also be opposition from Several of these are described here. pansion could be covered using the fed- policy-makers concerned about the cost California adopted legislation to allow eral GME funding described previously. of creating new residency positions and graduates of PGD programs to obtain In fact, as noted earlier, this mechanism the increased billing of dental services licensure in California without complet- has been used in the last few years to through any significant expansion of ing a clinical licensure examination. create 15 new programs and there is dental providers treating patients with However, relatively few graduates obtain the potential to create many more. Denti-Cal benefits. As just described, licenses using this mechanism and Advocates of this approach have the cost of creating new positions can program directors have not reported a referred to this approach as creating a be minimal if the federal GME mecha- significant increase in applications since required year of “service and learning” to nism is used. However, there will be a these regulations were adopted. It is not indicate the dual benefits of this strategy cost to any solution that increases care likely that this “optional” mechanism will in producing dentists better prepared to provided to underserved populations. have a significant impact on the number serve an increasingly complex popula- The challenge for oral health advocates of graduates seeking postdoctoral educa- is to demonstrate this cost will be more tion or on access to care in the future. than offset by reduced emergency room The alternative to expanding resi- the alternative to visits, hospitalizations, missed days of dency education through the current expanding residency education work and school, and other consequences optional mechanism is to enact a of poor oral health in these populations. requirement for mandatory primary care through the current optional residency training. There are a num- mechanism is to enact a Conclusions ber of ways this could be structured. Primary care residencies in dentistry Since relatively few (approximately 50 requirement for mandatory include GPR, AEGD, collectively known percent) graduates of California den- primary care residency training. as PGD, and PED. These primary care tal schools attend advanced education programs represent the largest group of programs, there could be a significant dental residencies, the fastest growing, increase in the number of dental school and the most likely to serve underserved graduates attending advanced educa- tion while at the same time providing populations during the training experi- tion programs if this was a requirement needed services to underserved popula- ence. An expansion of primary care dental for licensure. If new programs were tions during these training programs. residency positions in California has the developed in community health centers, Opposition to a required year of potential to positively impact access to then an increase in the workforce of “service and learning” will come from oral health care in California. However, approximately 300 dentists would be dental students opposed to lengthening there are significant political and financial added to the CHC system in California. the period of their educational pro- barriers to realizing this potential. If there were a requirement for com- gram before beginning dental practice. pletion of an advanced education pro- Although residents are paid a salary and references 1. Stevens RA, Graduate medical education: a continued his- gram prior to obtaining a dental license loans can be deferred, some are con- tory. J Med Educ 53:1-18, 1978. in California, as there is in New York, cerned there will be reduction in their 2. Glassman P, Meyerowitz C, Postdoctoral education in den- new positions would need to be created lifetime practice income. Many gradu- tistry: preparing dental practitioners to meet the oral health needs of America in the 21st century. J Dent Educ 63(8):615-25, to accommodate at least the gradu- ates of advanced education programs 1999. ates from California dental schools. A feel this is not the case as they are able 3. American Dental Association, Council on Dental Education. mechanism that has been proposed for to care for a wider variety of patients, Annual report of the Council on Dental Education. Chicago, American Dental Association, 1963. this expansion is to locate new programs perform a wider variety of procedures, 4. Neuman LM, Nix JA, Trends in dental specialty education and and positions in health centers. There complete them more quickly, and have practice, 1990-99. J Dent Educ 66(12):1338-47, 2003. are more than 250 health centers in Cali- a better understanding of how to run 5. Handelman SL, Meyerowitz C, et al, The growth of postdoc- toral general dentistry programs. Spec Care Dent 15:5-10, 1995. fornia that provide dental services and a practice than their peers who did not 6. Lynch M, Advanced general dentistry programs. J Dent Educ many of these have the capacity to host complete advanced education programs. 47:360-3, 1983.
46 january 2012 cda journal, vol 40, nº 1
7. Handelman S, Meyerowitz C, Iranpour B, Evaluation of ad- signs historic health care legislation. cdhp.org/resource/presi- vanced general dentistry education. J Spec Care 13(supp):176- dent_obama_signs_historic_health_care_legislation. Accessed 85, 1983. July 14, 2010. 8. American Dental Association, Commission on Dental 26. Atchison K, et al, PGD training and its impact on general Accreditation. Requirements for an advanced education dentist practice patterns. J Dent Educ 66(12):1348-57, 2002. program: general dentistry. Chicago, American Dental Associa- tion, 1980. to request a printed copy of this article, please contact 9. Glassman P, Accreditation of postdoctoral general dentistry Paul Glassman DDS, MA, MBA, director of Community Oral programs. J Am Coll Dent 62:27-30, 1995. Health, Arthur A. Dugoni School of Dentistry, 2155 Webster St., 10. Commission on Dental Accreditation, Standards for San Francisco, Calif., 94115. advanced education programs in general dentistry. Chicago, Commission on Dental Accreditation, July 1998. 11. Commission on Dental Accreditation, Standards for advanced education programs in general dentistry. Chicago, Commission on Dental Accreditation, July 2008. 12. Le H, McGowan T, Bailit H, Community education and community clinic finances. (Submitted for publication to J Dent Educ). 13. American Dental Association, Special committee on the future of dentistry. Strategic plan. Issue papers on dental CA-OCT-2011.pdf 1 10/6/11 8:01 AM research, manpower, education, practice and public and professional concerns and recommendations for action, July 1983. 14. American Association of Dental Schools, Proceedings of the 1992 House of Delegates, Resolution 11S-92-11. A year of postdoctoral study. J Dent Educ 56:454-5, 1992. 15. O’Neil EH, Health professions education for the future: schools in service to the nation. San Francisco, PEW Health Professions Commission, 1993. 16. PEW Health Professions Commission, Critical chal- lenges: revitalizing the health professions for the 21st century. San Francisco: UCSF Center for the Health Profes- sions, 1995. 17. Field M, ed, Institute of Medicine. Dental education at the crossroads: challenges and change. Washington, D.C., National Academy Press, 14, 1995. C 18. American Dental Association, Future of dentistry, execu- We are pleased to introduce our tive summary. Chicago, American Dental Association, HealthM Policy Resources Center, 2002. transition consultants for California: 19. Hayden K et al, Improving the oral health status of all Y Americans: roles and responsibilities of academic dental CM institutions: The report of the ADEA president’s commission. J Robert Smith Dent Educ 67(5):563-83, 2003. MY [email protected] 20. Health Resources and Services Administration, Financing dental education: public policy interests, issues and strategicCY considerations, 2005. CMY Steven Goldberg 21. Institute of Medicine and National Research Council. 2011. Improving access to oral health care for vulnerable K [email protected] and underserved populations. Washington, DC: the National Academies Press. 22. Mertz E, Anderson G, et al, Evaluation of strategies to Contact us at 1.866.898.1867 recruit oral health care providers to underserved areas of California. Center for California health workforce studies University of California, San Francisco. Prepublication draft, January 2004. 23. American Dental Association, 2009-10 survey of advanced Please expect a visit and/or phone call from dental education, March 2011. Approved PACE Program Provider FAGD/MAGD Credit your local PARAGON transition consultants Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement 24. Personal communication with Dr. Neal Demby, senior 4/1/2009 to 3/31/2012 vice president for dental medicine, Lutheran Health Care, July 14, 2010. Call 866.898.1867 or visit PARAGON.US.COM to sign up for our free newsletter 25. The Children’s Dental Health Project, President Obama
january 2012 47 Foundation_Oct_11_Journal_Sponsors.pdf 1 9/19/11 11:20 AM
Thanks to generous donations to the CDA Foundation, nearly 85,000 underserved Californians received oral health care in 2010, reflecting more than $12 million in services. The Foundation that started with a single employee and a sole purpose celebrates its 10th anniversary of transforming lives across California. The Foundation’s significant achievements include its work in community water flouridation, CAMBRA, the development of
C Perinatal Oral Health Guidelines and M the Student Loan Repayment Program, Y
CM which awards grants to new dentists MY in exchange for a commitment to
CY
CMY provide services to underserved
K communities that are most in need.
Creating smiles, changing lives.
Celebrating ten years!
Thank you to our supporters: study
cda journal, vol 40, nº 1
Economic Feasibility of Alternative Practitioners for Provision of Dental Care to the Underserved
anne matthiesen, mha, mba
abstract This study assesses the viability of three alternative practitioner types for provision of dental care to the underserved. Key factors modeled include compensation, training and practice costs, productivity, and payer mix scenarios. Utilizing dental therapists or dental health aide therapists is cost-effective for enhancing access. However, to be sustainable, the practices will require a subsidy or a better reimbursement than modeled. Without tuition support, the debt burden will deter applicants most likely to treat the underserved.
authors acknowledgments
Anne Matthiesen, mha, This study was funded ationally, there has been much culturally and/or socioeconomically diverse mba, is a manager with by the California Dental discussion of deploying alterna- background. This economic study is based ECG Management Association. The following tive dental practitioners to on a number of assumptions. The assump- Consultants, a firm people supported the offering a broad range study by volunteering resolve disparities in access to tions detailed below were developed to of strategic, financial, their time, expertise, data, dental care. New types of den- ensure maximum: transparency about operational, and and insight related to Ntal practitioners have been and are being the true, unsubsidized costs of providing technology-related the practice of dentistry: introduced without economic analysis of dental and training these practitioners; consulting services to Jared Fine, DDS; Huong their sustainability and its likely impact on applicability of costs of providing care in a health care providers. Le, DDS; Paul Reggiardo, DDS; and Brian Scott, their efficacy in addressing the access issue. variety of settings relevant to the under- DDS. The author also This study, commissioned by the Califor- served; and comparability of the practitio- wishes to thank Mary nia Dental Association and conducted in ners. The study also sought to apply the E. Williard, DDS, clinical March 2010, evaluated the dental thera- current research about the access benefits site director, ANTHC, pists (DT), dental health aide therapists of having a workforce that reflects the Division of Community Health Services; and Louis (DHAT), and advanced dental hygiene underserved population and, as a result, in- Fiset, BA, DDS, DENTEX practitioners (ADHP) with respect to corporated costs attendant to the success- curriculum coordinator, providing dental care for the underserved. ful education of underrepresented minor- MEDEX Northwest The study was constructed to focus on the ity and socioeconomically disadvantaged Division of Physician economic viability of the practice model, practitioners. Both public policy and other Assistant Studies, School of Medicine, for their the financial sustainability of the career external factors impact the outcome of generosity with their time for the practitioner, and the likelihood that this study, accordingly, assumptions about and data. the practitioner could be recruited from a loan rates, educational subsidies, practice
january 2012 49 study
cda journal, vol 40, nº 1
table 1
Comparative Characteristics of Typical Alternative Practitioners
DT DHAT ADHP Prerequisites High school High school High school or prior associate or bachelor in hygiene Training duration 18- to 24-month CC/technical school 18- to 24-month CC/technical school Varies by prerequisite. With a high program and preceptorship. Modeled program and preceptorship. Modeled school degree, a 72-month university- as 24-month as 24-month based program (as modeled)1 Compensation Salaried (exempt or hourly); Salaried (exempt or hourly); market- Salaried (exempt or hourly); market-based benefits based benefits market-based benefits Employment Employed by public health system Employed by public health system Employed by public health system (e.g., county, regional, state, school) (e.g., county, regional, state, school) (e.g., county, regional, state, school) Practice setting School or public health setting2,3 Predominantly public health settings3 Predominantly public health settings3 Billing practice Does not bill third-party commercial Does not bill third-party commercial Any payer. Bills third-party or government insurance on a or government insurance on a commercial or government insurance procedural basis4 procedural basis4 on a procedural basis Independence/ Dental supervision or remotely, using Dental supervision or remotely, using No supervision requirement. Referral supervision required teledentistry technology5 teledentistry technology5 of complex dental care only Scope of services Preventive, basic restorative, and Preventive, basic restorative, some Preventive, basic restorative, simple surgical services for children periodontal, and simple surgical, diagnostic, periodontal, prescribing (those under 21 years of age) (e.g., extractions of primary and authority, and simple surgical (e.g., permanent teeth) extractions of primary and permanent teeth)
Patient population Underserved children (50% or more of Underserved children and adults Underserved children and adults served6 the patients are on public insurance or (50% or more of the patients are on (50% or more of the patients are on receive free/reduced lunch) public insurance or are uninsured) public insurance or are uninsured)
1. A 24-month program after a four-year bachelor degree in dental hygiene. The 48-month program assumes hygienist training at the associate level. A 72-month program assumes only a high school degree. 2. The intention is for these services to be located so they are maximally accessible for children. 3. Services may be provided in a private practice clinic, assuming the patient population meets the definition provided. This analysis is not dependent on practice location. 4. Billing is performed by the employing entity (e.g., the community clinic, other public health service). 5. Supervision consists of standing orders. 6. The patient population is based on licensure limitations and is for modeling purposes to keep the practice settings compatible. finances, reimbursement rates, and other sion of dental care to the underserved. and also is the basis for the recently initi- critical factors are provided to inform the The DT model is based on the New ated Minnesota DT training programs. reader of the many variables as they cur- Zealand practitioner model. The DHAT Differences among practitioners rently exist. This should also remind the model is based on the Alaska DHATs include training duration, supervision reader that the economic viability of any trained in the DENTEX program through required, and the scope of services. DTs practitioner-based approach to dental ac- the University of Washington. The Alaska and DHATs have an ongoing supervision cess will be dependent on the existing mar- DHAT program was also modeled on the requirement, consisting of standing orders ket forces and the public policy response. New Zealand DT program, and the first and remote supervision using teledentist- Alaska DHATs trained in New Zealand. ry. DT and DHAT training is typicially an Practitioners Of the practitioner types in this analysis, 18- to 24‑month community college-type or The DT, DHAT, and ADHP training and the DHAT is the only model that has technical school-type program, followed by scope of practice are based on existing or active practitioners in the United States. a paid preceptorship. DTs and DHATs also proposed practitioner types with modifica- The ADHP model was developed by the have an intensive biannual accreditation tion for model comparability and for provi- American Dental Hygienist’s Association process. This analysis assumes a 24-month
50 january 2012 cda journal, vol 40, nº 1
table 2
Annual Mean Salary Data for Dental Practitioners, 2008, and ADHP Estimate
State Dentist1 DH Average of Positions Alternative Practitioner Salary Alaska $203,000 $92,300 $147,650 $154,112 California $140,990 $85,030 $113,010 $117,956
1. Source: Bureau of Labor Statistics, Occupational Employment and Wages, 29-2021 Dental Hygienists and Dentists, May 2008. Annual wages have been calculated by multiplying the hourly mean wage by a year-round, full-time hours figure of 2,080 hours; for those occupations where there is not an hourly mean wage published, the annual wage has been directly calculated from the reported survey data.
table 3
Annual Mean Salary Data for Dental Practitioners, 2008, and DT/ DHAT Estimate
State DH1 DA Average of Positions Alternative Percentage Difference Practitioner Salary2 Alaska $92,300 $41,830 $67,065 $70,000 104% California $85,030 $33,910 $59,470 $62,073 104%
1. Source: Bureau of Labor Statistics, Occupational Employment and Wages, 29-2021 Dental Hygienists and Dental Assistants, May 2008. Annual wages have been calculated by multiplying the hourly mean wage by a year-round, full-time hours figure of 2,080 hours; for those occupations where there is not an hourly mean wage published, the annual wage has been directly calculated from the reported survey data. 2. According to Mary Williard, DDS, DHATs earn between $60,000 and $80,000. The average is applied here. To estimate the California salary requirement, applying the ratio of this to the average of the DH and dental assistant (DA) salary results in $62,073. training period and includes a preceptor- these settings, billing is usually done by levels and other practice opportunities. ship for both the DTs and DHATs. They the employing entity and is likely to be on Given that the DT/DHAT and ADHP are only distinguished by the age of their an encounter rather than procedural basis. will have a scope of practice that covers patient populations. The DT sees only However, in this analysis, practice costs many basic functions of a dentist, absent patients under 21, whereas the DHAT and are modeled to be independent of setting other barriers, the practitioner would soon ADHP serve all ages. The ADHP may prac- and reimbursement scenarios are based be recruited to function within a dental tice and bill independently within a defined on a blend of payers and procedural billing practice at a salary similar to that of an scope of services and has no postgraduate assumptions relevant in California. The pa- employed dentist or, at minimum, a dental preceptorship requirement. ADHP training tient population for the practitioner types hygienist (DH) (as provided in table 2). is university-based and similar to dental defined above would be underserved chil- In the Minnesota DT model and in school in scope and duration (six years). dren or underserved children and adults. Alaska, the retention concern was ad- Although the typical applicant has previous In this case, underserved is defined as 50 dressed by limiting the scope of practice. hygiene education and completes a shorter percent or more of the patients on public In addition, sustainability of the career is course of study, for comparability to the DT insurance or uninsured. Typical practitio- a function of debt level relative to income. and DHAT, ADHP training costs are mod- ner characteristics based on enhancing ac- In Alaska, sustainability was addressed by eled beginning with a high school degree. cess for the underserved are summarized establishing funding to prevent DHATs For the purpose of model comparabil- in table 1. Specific practitioner features in from incurring educational debt and by ity and based on the objective of providing this analysis are further detailed below. predetermining salaries through employer dental care to the underserved, training contracting with students prior to initia- prerequisites, employment, practice set- Dental Practitioner Economics — tion of their training. To date, DHAT prac- ting, and billing practice are the same for Retention and Sustainable Salary titioners have been successfully recruited all practitioners. The practice setting is Alternative practitioners recruited and retained within the desired practice expected to be a public health setting. This to practice in an underserved setting settings at compensation ranging from may be a community clinic, a mobile van, must find it economically feasible to $60,000 to $80,000. This is approximately or, in the case of the DT, a school clinic. In do so relative to their educational debt the average Alaska salary of the DA and
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table 4
Annual Tuition Estimates for Dental Practitioner Programs, Class Size 30
DH DT Dentist California CC1 University of Western University of Alaska DHAT University of University of Nebraska2 Career Minnesota4 Program5 Washington6 Nebraska7 College3 Tuition (actual)8 $8,543 $13,818 $28,651 $10,033 $50,645 $22,006 $31,500 Actual class size 20 24 30 12 30 55 45 Total program cost $170,850 $331,632 $859,515 $120,400 $1,519,347 $1,210,330 $1,417,500 (annual)9 Annual cost per student, $5,695 $11,054 $28,651 $4,013 $50,645 $40,344 $47,250 class size 30 students10 Estimated $53,068 $62,152 unsubsidized tuition11
Note: All information based on information accessed February-March 2010. 1. Based on tuition information posted on Cabrillo College website. Assumed to be representative of tuition at California CCs. 2. 2009 to 2010 DH program tuition costs. Source: University of Nebraska website. 3. Source: Mr. Freddie Sinsua, admissions representative, Western Career College. 4. Tuition basis for both the baccalaureate and master’s degree programs is the University of Minnesota undergraduate tuition. The program duration is eight semes- ters, excluding prerequisites. Source: Mr. Jeff Karnitz, principal office specialist, Office of Admissions, Office of Academic Affairs, University of Minnesota, School of Dentistry. 5. Source: Mary Williard, DDS, Alaska Native Tribal Health Consortium (ANTHC) DENTEX program director. ANTHC and University of Washington School of Medicine MEDEX Northwest Division of Physician Assistant Studies. Dental Health Aide Training Program. 6. Source: University of Washington School of Dentistry website. 7. Source: University of Nebraska College of Dentistry website. 8. Based on resident tuition rates for a year. With the exception of the DHAT program, each of these has prerequisites of 1.5 to three years; reported tuition represents the technical portion of training related to the degree. 9. Total program cost is estimated based on current enrollment. 10. This calculation approximates the cost of other programs, assuming total program costs are fixed as student costs increase or decrease. Modifying programs for class size did not take into account changes in cost structure that might occur as a program is expanded or contracted. The greater the difference between actual and adjusted class size, the less reliable the results. However, in most cases, the class size of 30 will be more representative of expected costs. 11. Unsubsidized tuition calculated based on the assumption that tuition represents 16.8 percent of total program revenues and other funding sources represent 28.2 percent.
DH who both have a similar training dura- that limit their ability to function as DH’s a public health setting. Given the total tion and practice under a dentist’s supervi- post-training. Since there are no other educational duration, it is reasonable sion.1 See table 3 for the U.S. Bureau of La- sources of information about salaries for that compensation would be similar. bor Statistics data on DH and DA salaries the modeled practitioners, this analysis is To assess whether this compensation for 2008 in Alaska and California.2 Assum- initiated by assuming a similar ratio could level is sustainable for the DT, DHAT, ing a midrange of $70,000, this is approxi- be successful in California; the DHAT and ADHP, the study estimated training mately 104 percent of average DA and DH salary would have to be approximately expenses and associated educational debt. salary. It is noteworthy that this is a lower $62,000. However, as in Alaska, barriers to compensation that the DH in spite of a functioning as DH’s in physician practices, Dental Practitioner Economics — greater scope of practice. It is likely that or otherwise limiting their practice to the Tuition Expenses this is possible because of a combination underserved, would have to be in place. In order to fully consider the econom- of barriers preventing future DHAT practi- Applying this same methodology ics of a new practitioner type, this model tioners to compete for DH jobs: 1) They are to the ADHP, comparing the educa- estimates the unsubsidized tuition cost/ recruited into the program at a time that tional duration and freedom and scope of true cost of educating the DT, DHAT, and they are not competitive candidates for practice to dentists and DHs, results in ADHP. Tuition costs of current DHs, DTs, DH program; 2) The selection process se- a salary of nearly $118,000. It is notable and dental schools were reviewed and are lects for commitment to their underserved that this level of compensation is similar provided in table 4. However, there are community; 3) There are license barriers to that received by a dentist practicing in several indications that these, unadjusted,
52 january 2012 cda journal, vol 40, nº 1
are not good proxies for the true cost of estimated unsubsidized cost of dental when compared to other tuitions and only educating alternative practitioners. There school was as much as or slightly more includes the costs for students entering is a noticeable variance in annual tuition, than that of the Alaska DHAT program. with a hygienist associate or bachelor which seems independent of program type. It is not surprising that dental school degree. For comparison to the DT and For example, based on reported tuition, and DHAT programs would have compa- DHAT, total ADHP tuition costs must the yearly cost of a DH program is as much rable and higher costs than DA or DH pro- also include all post-high school training. as that of a dental program, and the DT grams. Regardless of total class size, the Accordingly, it is assumed that training programs are both more and less expensive clinical nature of training requires a maxi- includes a prerequisite general educa- than the DH or dentist education. This is mum 8:1 ratio of students to instructor. tion element similar to a DH program or likely due to variance in class size as well as Furthermore, dental practitioner training associate degree program and is followed some programs (e.g., public institutions) programs require dentist instructors com- by an intensive clinical element in the last receiving subsidies that reduce the cost paid pared to hygiene or assistant programs three years, requiring smaller and more by the student. Accordingly, adjustments that may have hygienist instructors. expensive student-to-dental-instructor were made to better estimate actual costs ratios. The first three years of the ADHP and expected tuition for each practitioner. program costs are based on the estimated First, programs were adjusted for class unsubsidized college costs, represented size. Assuming that the tuition per student regardless of total by the Western Career College tuition multiplied by the class size reflects the total class size, the clinical adjusted for class size (table 4). The last cost to operate the programs, this total pro- three years are based on the unsubsidized gram cost was divided by a class size of 30 nature of training requires cost levels of the Alaska DHAT program, to estimate per student costs (table 4). The a maximum 8:1 ratio of since these years represent the clinically resulting tuition levels suggested that great intensive portion of the program, and variances in tuition for similar programs students to instructor. the scope of practice will require equip- might be due to subsidies. For example, ment and faculty levels similar to the the tuition in the for-profit Western Career other alternative practitioner programs. College DH program is several times more expensive than the community colleges Given that the Alaska program is the ba- Dental Practitioner Economics — or public university-based programs, sis for the DT and DHAT practitioner types, Cost of Living which are known to be subsidized. unsubsidized tuition costs were available, Cost of living typically includes some Second, since unsubsidized tuition and the level of instructor and student-to- fees, books and supplies, room and board, costs were not available for all of these instructor ratios are as would be expected in transportation, and personal expenses programs, several modifications were the new practitioner programs, the Alaska (e.g., health insurance). For the maximum made to the these costs, and choices were DHAT program tuition was used in the cost and broadest applicability, these esti- made about the most appropriate and model of DT/DHAT practitioner economics. mates are based on 12 months living away comparable estimates of actual tuition Although the cost of living is typically high- from home for a single person. The annual expected for the DT, DHAT, and ADHP er in Alaska, this is offset by other program average of cost-of-living estimates from programs, based on their particular char- costs that are lower than expected in other the financial aid offices of various pro- acteristics. According to a 2004 American settings (e.g., the Alaska DHAT program grams, $17,057, was applied in the model. Dental Association (ADA) study of the administrative overhead is approximately The tuition, cost of living, and resulting economics of dental education, public 10 percent of the total program cost). total expenses for the DT/DHAT and ADHP dental schools received only 16.8 percent Unlike the DT/DHAT programs, there degrees are provided in tables 5 and 6. of their funding through tuition and are no current ADHP programs appro- fees, state and local subsidies, as well as priate to use for estimating tuition. The Dental Practitioner Economics — philanthropic support, represent nearly 55 Minnesota DT program is based upon Debt Burden percent of total program revenues.3 Once the ADHP model; however, tuition at The rising debt challenge in medi- the tuition was adjusted accordingly, the the state university is clearly subsidized cal school and dental schools is well-
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table 5
Total Tuition and Cost-of-Living Estimate, DT/DHAT
Cost Tuition1 $101,290 professional students, the total limit Living expenses2 $34,113 is $138,500, with an interest rate of 6.8 Total expenses for degree $135,403 percent (the 2010 and prevailing rate). While it is not clear whether graduate 1. Based on DHAT program expenses modified for a class size of 30. or undergraduate loans would apply to 2. Estimated living expenses are based on an average of various program estimates of costs per year. These the DT, DHAT, and ADHP degree, no costs are multiplied by the two-year program duration. government loans will cover the full loan amount required. Furthermore, the table 6 loan term is limited to 10 years, which results in a high annual payment. table 7 Total Tuition and Cost-of-Living Estimate, ADHP demonstrates the annual payment level Cost at the 6.8 percent rate and 10-year term, Tuition (3 Years)1 $ 85,952 assuming it could cover the full loan. Tuition (3 Years)2 $151,935 For comparison, the resulting debt level for the public health dentist is included, Living expenses $102,340 assuming four years of undergraduate Total expenses for degree $340,226 school and four years of public dental Note: Figures may not be exact due to rounding. school with the same average cost of liv- 1. Assumes the first three years are based on the cost structure of an unsubsidized technical college tuition ing as for the other degrees. The result- (see table 4), similar to the hygiene program prerequisite to the current MN DT (ADHP type) program. ing numbers substantiate California’s 2. Assumes the last three years are based on DHAT program costs modified for a class size of 30. (See table 4). Program requirements and cost structure being similar to the intensive and university-based challenge to fill public health dentist DHAT, MN DT (this model’s ADHP), or dental school programs. vacancies, particularly with socioeco- nomically disadvantaged applicants that would be able to serve their communi- documented as are its implications: the earning potential. Furthermore, both the ties of origin. Even for the alternative limitations of financing, the effect on DHAT experience and academic support providers, these debt levels are high. practice selection, the adverse effect on suggestions for disadvantaged applicants Assuming no federal subsidy was avail- enrollment by students of lower socio- suggest that programs that successfully able for this course of study, a private loan economic status, and underrepresented train providers to treat the underserved would be necessary. Loan terms, rates, and minorities.4 Debt levels must also be deter students from working while in maximums vary; however, the best private evaluated for alternative practitioners. It school. To further standardize the model loan terms are available to those with good is important to understand the factors for all socioeconomic levels, it is assumed credit ratings who also have a credit-wor- that determine debt level to intervene as that the student and his/her parents thy cosigner. Considering the underrepre- necessary to avoid the negative impacts would not have savings to contribute to- sented minority (URM) and socioeconomi- seen in other health professions. ward the cost of tuition. Accordingly, the cally challenged applicant, the highest rates In addition to living costs, tuition, debt model anticipates that students will would be applied. The advantage of these and program duration, debt level is based have to borrow the full tuition and living loans is that they have higher maximums on available savings, family contribu- expenses associated with the program. and longer repayment periods. However, tion, income during study, loan terms Rates, terms, and availability of the maximum loan for health professions and grants. Debt burden is measured government and private loans vary is $225,000. table 8 demonstrates the an- relative to income level post-training. based on debt level and degree pursued. nual payment assuming the full training Based on the intensive nature of the Both government and private loans cost was borrowed for a 25-year term and programs and the level of education of have limitations. Although government at 10 percent interest (based on loan avail- the entering student, it is anticipated loans may be available, for undergradu- ability and prevailing rates in March 2010). that students will be unable to earn ate students, the combined subsidized Opinions vary regarding what is consid- significant income while in school. High and unsubsidized limit is approximately ered an excessive debt burden. Some sourc- school students have limited part-time $10,000 annually. For graduate and es recommend that educational loan pay-
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table 7
Debt Estimate, Government Loan
Annual Income DT/DHAT ADHP Dentist After Debt Practitioner salary $62,073 $117,956 $118,000 populations are practitioners from those Educational debt $19,101 $47,994 $70,484 communities, the economic deterrents to Net income/(loss) $42,972 $ 69,962 $47,516 education and practice are even higher for these potential students and practitioners.
Debt burden DT/DHAT ADHP Dentist Addressing the Debt Problem Total loan amount $135,403 $340,226 $499,661 The most likely source of sup- Annual debt expense $19,101 $47,994 $70,484 port would be the state/public health Salary $62,073 $117,956 $118,000 infrastructure/employer through
Debt percentage 31% 41% 60% subsidies for schools providing the of salary training or provision of tuition grants or debt waivers to students. Note: Net income and salary have not been adjusted for income taxes and Social Security. One of the most efficient ways of addressing the debt problem is to table 8 minimize training duration and subsi- dize educational costs directly. By using Debt Estimate, Private Loan less-direct approaches, such as loan Annual Income DT/DHAT ADHP Dentist repayment for service in underserved After Debt areas, or through greater salary levels, Practitioner salary $62,073 $117,956 $118,000 a portion of the subsidy accrues to the Educational debt $14,917 $37,482 $51,289 financial institution. The Alaska DHAT program recognized the debt issue and Net income/(loss) $47,156 $80,474 $66,711 has addressed it by having the future employer, the tribal organizations, pay Debt burden DT/DHAT ADHP Dentist both the living expenses and tuition Total loan amount $135,403 $340,226 $465,548 directly. Furthermore, the program Annual debt expense $14,917 $37,482 $51,289 does apply for and receive some educa- Salary $62,073 $117,956 $118,000 tional grant subsidies. Such subsidies were critical in initiating the program. Debt percentage 24% 32% 43% of salary Depending on the loan, a total subsidy of approximately $50,000 to $70,000 is required for the DT/DHAT program, and $312,000 to $346,000 ments not exceed 10 percent to 15 percent debt higher than $300,000. Based on is required to keep the ADHP pro- of income. Others suggest that the debt the information above, it is unlikely that gram at a 15 percent debt burden. should be no more than the annual start- dentists with such debt levels would Assuming no tuition support or ing salary. As an indication of maximum practice in a public health setting. program subsidy, the alternative would burden, banks typically refuse loans if total Actual loans are likely to be a blend be salary support. Based on a career of debt payments, including home, car, and all of government loans and private loans, 25 years, the salary required to meet the other loans, exceed 37 percent of income. as well as grants or other student aid.5 annual private debt payments would be Based on these metrics, even the However, regardless of the combination, approximately $100,000 for a DT/DHAT private loans are barely sustainable for additional support is required for the debt or $250,000 for an ADHP. Assuming a the DT/DHAT, whereas neither private level to be sustainable for applicants from government loan of 10 years, the sal- nor government loans would be sus- all socioeconomic tiers. Given the research ary would need to be higher during the tainable for the ADHP. In 2008, only suggesting that those most likely to loan term to keep the debt ratio under 10 percent of dental students reported serve the poor, uninsured, and minority 15 percent. Clearly, these compensation
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table 9
Billing Codes Within the New Practitioner’s Scope of Practice Codes Description D0120 Periodic oral evaluation — established patient levels are higher than the market pays D0140 Limited oral evaluation — problem focused for education of comparable duration D0150 Comprehensive oral evaluation — new or established patient and cannot be sustained by the clinical D0210 Intra-oral — complete series revenues received in underserved areas. D0220 Intra-oral — periapical first film Result of Practitioner Economic D0230 Intra-oral — periapical each additional film Analysis D0272 Bitewing — two films The unsubsidized cost of training is D0274 Bitewing — four films lowest for the DT/DHAT and is below the D0330 Panoramic film 37 percent maximum loan ratio. However, regardless of loan type or term, none D1110 Prophylaxis — adult of the practitioner types meet the test D1120 Prophylaxis — child of a reasonable debt burden. Further- D1203 Topical application of fluoride — child more, only the DT/DHAT program loan D1204 Topical application of fluoride — adult amount falls within the maximum loan D1351 Sealant — per tooth limits. Clearly, none of these are sustain- able without tuition subsidies, grants, D1510 Space maintainer — fixed unilateral or other approaches to decreasing the D1515 Space maintainer — fixed bilateral debt burden. Relative to the ADHP and D2140 Amalgam — one surface dentist, the DT/DHAT program is more D2150 Amalgam — two surfaces economical to subsidize, whether through D2160 Amalgam — three surfaces tuition or direct salary augmentation. D2330 Resin-based composite — one surface, anterior Practice Economics D2331 Resin-based composite — two surfaces, anterior For the purpose of understand- D2332 Resin-based composite — three surfaces, anterior ing the economics under the simplest D2335 Resin-based composite — four or more surfaces, anterior practice model, the dental practice is D2391 Resin-based composite — one surface, posterior modeled based on the assumption that each practitioner operates with one chair D2392 Resin-based composite — two surfaces, posterior and a DA. This is the minimum space D2930 Prefabricated stainless-steel crown — primary tooth and assistance required, regardless of D2931 Prefabricate stainless-steel crown — permanent tooth whether the practice is in a mobile clinic, D2940 Sedative filling (interim therapeutic restoration) a school-based setting, an independent D2970 Temporary crown rural practice, or within a larger den- tal or medical clinic. Dentists typically D3220 Therapeutic pulpotomy have at least two chairs and assistants, D3221 Endodontic — pulpal debridement and practice profitability is associated D4341 Periodontal scaling with a greater number of operatories D4355 Full-mouth debridement and assistants. However, alternative D7111 Extraction, coronal remnants — deciduous tooth practitioners, by virtue of their scope of practice, reimbursement mix, and the D7140 Extraction, erupted tooth or exposed roots communities in which they serve, will D9110 Emergency (palliative) treatment have limited ability to enhance their Note: Some codes may be primarily performed on adults or children. Other codes within the scope of practice practice income through the scale or may be performed infrequently. services typically provided by dentists practicing under a multioperatory model.
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table 10
Estimated Collections Payer Mix A Payer Mix B Payer Mix C Public Health Practice1 DT DHAT/ADHP DT DHAT/ADHP DT DHAT/ADHP $109,738 $99,617 $152,028 $148,607 $202,218 $200,913 $235,205 1. Actual collections for one FTE in a public health practice adjusted to 60 percent productivity based on one operatory and assistant and to 1,900 hours for one FTE.
Revenue Assumptions payers. Private plan rates are median Staff Revenues are defined by three values from the ADA 2007 Survey of This model assumes each practitioner elements: type of procedures/scope of Dental Fees. The pediatric values are from is supported by one nonregistered DA, services, productivity, and reimburse- the table of national pediatric dentists. paid a salary of approximately $35,000, ment. table 9 provides a list of procedures The adult reimbursement is based on and a benefits rate of 27.5 percent ($9,626). within the scope of practice of a new general practitioners in the Pacific region. practitioner that are used for modeling The sliding-fee reimbursement is as- Supervision Compensation practice revenues. In addition to these sumed to be 30 percent of the private Approximately $3,000 is included in procedures, the ADHP has diagnostic plans. It is important to note that the the DT and DHAT practice expenses for and prescribing authority; however, DHAT and ADHP have the same reim- annual compensation to a supervising these are not included in the financial bursement rates, but the DT rates are dentist for the provision of biannual analysis as they cannot be billed. pediatric-specific due to this assumed accreditation and daily supervision Revenues are modeled based on limitation on the DT scope of practice. duties. Based on the Alaska DHAT estimated procedures and the associated The resulting revenues for the DT and experience, daily time requirements reimbursement. The procedural mix from DHAT/ADHP are provided in table 10. are minimal – five minutes to preview a public health setting within the new Payer Mix C most closely replicates the and review the day, with additional practitioners’ scope of practice is used collections attained by a dentist in the contact when there is an issue (this is to estimate the number of procedures public health setting. Since Payer Mix C is described as similar to being on call, performed by each new practitioner. Pro- a better payer mix (i.e., it includes private requiring response within five minutes). ductivity is adjusted to one operatory and dental plan reimbursement) than that The most time-intensive requirement is DA, which is assumed to be 60 percent of of the public health practice, the differ- the two‑week biannual review. How- the productivity of a public health dentist ence must be due to highly reimbursed ever, this is completed in the super- with two operatories and assistants. procedures specific to dentists. It is also vising dentist’s office and is billable. Furthermore, one FTE practitioner is as- noteworthy that DT revenues are higher Expenses are estimated based on: sumed to be clinically active 1,900 hours than DHAT/ADHP revenues. This is due n One week (40 hours) per year (an per year. Administrative functions are to several DT procedures being performed average of the biannual accreditation assumed to be limited based on practicing more quickly for children. The result- period). within a larger public health setting and ing productivity outweighs the minor n An average of 15 minutes per day (40 are not included in the practitioner costs. and limited reimbursement differentials hours annually based on 52 weeks). Three different payer mixes are between adult and pediatric procedures. No precepting costs are included. The modeled: supervising dentist has typically served Payer Mix A: 75 percent Denti-Cal and Expense Assumptions as the preceptor for the DT/DHAT that 25 percent sliding-fee scale. he/she supervises. Minimum precep- Payer Mix B: 50 percent Denti-Cal, 25 Practitioner Compensation torship duration is 400 hours and may percent sliding-fee scale, and 25 percent Practitioner compensation is based be longer as required by the precep- average private dental benefits plan. on a ratio of compensation of dental tor; however, costs are not included Payer Mix C: 50 percent Denti-Cal and 50 practitioners with similar educational in the model, as the DT/DHAT is bill- percent average private dental benefits plan. durations (DA, DH, dentist, etc.) and able during this period and it is a one- The Denti-Cal fee schedule is used to actual average compensation of the time expense to the training program represent reimbursement for government Alaska DHAT (see tables 2 and 3). rather than an ongoing practice cost.
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table 11
Practice Financial Projections for Three Payer Mixes
DT DHAT ADHP Payer mix1 A B C A B C A B C Revenue $110 $152 $202 $100 $149 $201 $100 $149 $201 Expense Practitioner compensation $79 $79 $79 $79 $79 $79 $150 $150 $150 Ancillary salary and benefits $48 $48 $48 $48 $48 $48 $45 $45 $45 expense2 Other operating expense $70 $70 $70 $70 $70 $70 $70 $70 $70 Total expenses $197 $197 $197 $197 $197 $197 $265 $265 $265 Net income/(loss) $(87) $(45) $5 $(97) $(48) $4 $(165) $(116) $(64) Clinical revenue percentage 56% 77% 103% 51% 76% 102% 38% 56% 76% of expenses
Note: Dollars in thousands. Annual income/(loss). Based on one operatory at 60 percent productivity of a two-operatory model. 1. Payer Mix A: 75 percent Denti-Cal and 25 percent sliding-fee scale. Payer Mix B: 50 percent Denti-Cal, 25 percent sliding-fee scale, and 25 percent average private dental benefits plan. Payer Mix C: 50 percent Denti-Cal and 50 percent average private dental benefits plan. 2. Ancillary salary and benefits for DAs and for a supervising dentist for the DT and DHAT.
Depreciation and Finance Expenses are identified as minimal and incremental Results Equipment expense includes deprecia- requirements. It is assumed that other table 11 presents a summary of tion and financing totaling $20,000, based amenities or spaces will part of the larger the net income or loss for each on clinical equipment totaling approxi- setting (e.g., bathrooms would be available practitioner under various payer mix mately $67,000 and a laptop. Due to the within the school or larger clinic setting). scenarios. The ADHP model is not similarities in practice scope, it is assumed Lease costs are based on average annual sustainable in any scenario. Payer all practitioners require the same equip- lease costs for medical/dental buildings Mix C breaks even for the DT and ment. The equipment expense estimate was in several dental health provider shortage DHAT; however, it is unlikely that a provided by Patterson Dental, a national areas (HPSAs). Resulting lease costs are ap- payer mix consisting of 50 percent distributor of dental equipment and is proximately $6,000 annually. While rent/ reimbursement from private dental based on installation of one low-end opera- lease expenses would not be applicable in a plans would be present in a public tory with equipment required for practicing mobile setting, it is expected that this set- health clinic. It is common for public in a broad number of settings. No specific ting would result in other comparable costs health settings to have a net loss and teledentistry equipment is included beyond (e.g., gas, vehicle, insurance, maintenance). require additional grant support or intraoral cameras, which are also used for other forms of subsidy. As table 11 reimbursement purposes. This decision Other Operating Expenses indicates, for the DT and DHAT, Payer to exclude this equipment is based on the Approximately $44,000 in expenses Mix B revenues cover nearly 80 percent considerable additional cost, approximately is estimated based on analysis of of expenses, which is similar to other $10,000, and because supervision can be actual data from a public health set- public health settings. provided without it. Currently, most Alaska ting applied on an FTE basis. Office Ultimately, these findings suggest DHATs practice without sophisticated supplies include telephone, postage, that with procedural-based teledentistry equipment, managing with a copier, general office supplies, subscrip- reimbursement and a public health digital camera and email/telephone contact. tion, printing, etc. Based on the types payer mix (Payer Mix A), these clinics of procedures performed external lab cannot break even. Although the DT Rent/Lease Expense services are expected to be nominal and and DHAT provide a more efficient Space costs are based on standard are included in miscellaneous expenses. model of care than the ADHP, based dental office area square-footage require- This also includes maintenance costs on a one-operatory model, they will ments. Approximately 400 square feet and nonspecified office overhead. require additional support.
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table 12
Encounter-Based Revenue Estimate
Productivity Statistics Procedures Visits Encounter-Based per FTE per FTE Revenue One provider, two operatories1 6,828 3,099 N/A need is greatest. Studies suggest that One provider, one operatory (60%)2 4,097 1,859 N/A the programs that are most successful DHAT/ADHP3 3,438 1,560 $195,049 in placing and retaining practitioners in underserved areas recruit practitioners DT3 4,191 1,902 $237,769 who are socioeconomically and cultur- 1. Based on data provided for a public health setting. It is assumed that this is per FTE based on a model of ally similar to those populations they will one provider with two DAs and two operatories. Provider hours are 1,800. serve. However, URMs and the socioeco- 2. Estimated per FTE productivity for one DA and operatory, based on the ratio of procedures to visits from the data above. Provider hours are 1,800. nomically disadvantaged are challenged 3. Procedure volumes consistent with other analysis. Visits per FTE estimated based on an assumption of in obtaining higher levels of education 2.2 procedures per visit from the public health clinic data above. Visits paid at $125, which is comparable to as well as bearing the cost of training. current encounter-based receipts in the public health setting. The burden of educational debt decreases the likelihood that URMs will practice in underserved areas.6 Understanding the Variables and Alternatives — as a reduction in the hourly compensa- relationship between diversity, debt, and Making the Economics Work tion). Although a two-operatory model service is key to crafting approaches that is considered more efficient, it does address access by successfully recruiting What Adjustments Might Result in a not alter the outcome. Due to volume and retaining disadvantaged candidates. Sustainable Practice Model? or space constraints, it is unlikely to There are few opportunities for be an option for many settings. The Diversity Challenge expense-side reductions, and none are The greatest and most realistic Statistics indicate that in California, considerable enough to reach break-even. impact on the revenue side of the model the highest rate of untreated cavities in Rent and equipment expenses can be would be a shift to visit‑based reim- children is in Mexican-Americans and, slightly reduced by co-locating the practi- bursement. Visit-based reimbursement secondarily, in other nonwhite races/ tioner within a current dental practice set- greatly increases the viability of the DT ethnic groups.7 Several studies of health ting (e.g., approximately a $6,000 reduc- and also the DHAT model. Assuming care practitioners have indicated that tion in finance and depreciation expense). $125 for all visits, the DT and DHAT minorities are more likely to practice in Incremental productivity assump- break even. (table 12 estimates expected minority communities.5 According to the tions and working hours have a sig- revenue for this payment approach.) Healthy People 2010 companion docu- nificant impact on the sustainability of Encounter-based reimbursement is ment on workforce development, minor- the practice but may be less realistic. also key to long-term practice sustain- ity physicians are more likely than their Increasing productivity to 70 percent ability and functions as an incentive to white counterparts to serve in commu- of the two-operatory model results in meet public health goals. In contrast, as nities where there is a shortage of physi- an additional $20,000 to $35,000 to the practitioners successfully impact dental cians and to treat minority patients.8 margin and nearly attains break-even for health, income from higher procedural- This suggests that successfully address- the DT and DHAT Payer Mix B. Increas- based billing codes will be reduced. ing the access issue will require recruit- ing annual clinical working hours to ing dental practitioners from these 2,000 hours adds $7,000 to $11,000 to Critical Elements in Access — Linking populations. Currently, some minori- the margin, but is unlikely to occur given Diversity and Economics ties are underrepresented in advanced the operating hours in a typical public The purpose of exploring new dental degrees. Black and Latino dental health setting, particularly a school-based practitioner models is to provide the health practitioners are most highly setting, or be an economically reasonable underserved with access to dental care. represented as DAs, a job that requires expectation given employment condi- One aspect of this is ensuring that the the lowest education level (table 13). tions for other dental practitioners (i.e., practitioner models are economically Studies document the challenges increasing expected work hours relative viable; however, simply increasing the of recruiting and retaining socioeco- to other practitioners would adversely supply of practitioners will not guaran- nomically disadvantaged minorities impact choice of career and function tee they will practice in areas where the in the medical and dental professions.
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table 13
Dental Worker by Race, 20089
Practitioner White Black or African Asian Hispanic or Latino Total Minorities URMs1 American Dentist 80% 3% 12% 5% 21% 9%
DH 89% 4% 2% 5% 11% 9%
DA 74% 7% 2% 17% 26% 24%
1. The Institute of Medicine committee defined underrepresented racial and ethnic minorities as African Americans, Hispanics, and Native Americans – groups that are both underrepresented and characterized by a group history of deprivation. Source: Kelley WN, Randolph MA, (eds), Careers in Clinical Research: Obstacles and Opportunities, Institute of Medicine, National Academy Press, Washington, D.C., 1994.
Recruitment challenges include: n Presenting an inclusive image in and family histories, and the personal n Being aware of the opportuni- program marketing materials; challenges applicants had to overcome ties available (e.g., role models in n Appointing minority outreach/ in order to obtain an education.14 applicants’ earlier years, recruiting recruitment coordinators; The Alaska DHAT program has em- outreach to these populations); n Supporting students through the ployed some of these efforts and more n Having adequate prerequisites for application process; with considerable success. The program’s admission. On average, when compared n Mentoring students for the extensive efforts start with developing a with white students, racial and ethnic educational duration; and targeted pipeline of recruits and continue minority students receive a K-12 educa- n Providing Head Start classes that with supportive measures throughout the tion of measurably lower quality, score target skills to successfully transition to educational program, as well as strate- lower on standardized tests, and are professional school (e.g., computer, gies that ensure professional success less likely to complete high school10; reading comprehension, math, study and retention in URM communities. n Encountering barriers in the skills, writing). California educational system to selecting Programs report that these types of Cost of Training and Debt applicants based on minority status; and efforts result in 77 percent to 100 percent Although prerequisites and approach n Having the financial resources to increases in minority enrollment and are important in recruitment and re- attend training. retention rates of up to 94 percent. Other tention success, the costs of training Financial barriers to URM enrollment programs have had success by increasing and the associated debt must also be include high and rising tuition, higher liv- the competitiveness of URM applicants to addressed.4 The issue here is twofold: ing costs at schools in major metropolitan dental school with summer enrichment cost is a barrier to entry and to choos- areas, higher tuition at private schools, and programs for undergraduate students ing to practice in underserved areas. school location far from the applicant’s focusing on study skills and self-man- Expected debt level impacts choice hometown. Furthermore, studies suggest agement skills, including time manage- of profession. A 1998 Association of that both recruitment and retention can be ment, promptness, and organization. American Medical Colleges (AAMC) impacted by the reputation or experience of In addition, these programs strengthen study found that premedical students are schools being unwelcoming to minorities, students’ background in the basic sciences dissuaded from medical careers because being academically too challenging, or not and provide counseling and mentoring to of financial concerns. Students of color having sufficient URM students and faculty ensure selection of appropriate prerequi- cited the cost of medical schools as the to serve as role models and mentors.11 sites and to support applicants through primary reason for not pursuing medi- the dental school admissions process.13 cal careers. Similarly, a 2002 ADA study Addressing the Diversity Challenge The Disadvantaged Student Recruit- indicated that decreased admissions Educational eligibility and access are ment Manual for California Dental among black and Hispanic students pipeline issues that have to be addressed Schools recommends similar ap- may have been due to cost increases in well in advance of professional education. proaches. It also recommends “whole- dental education.15 This impact is likely The American Association of Colleges file review” of applicants, rather than a to be greater for minority and socio- of Nursing (AACN) published an article grade- and test score-centric selection economically disadvantaged students. that addressed the issue of attracting a process. This approach emphasizes Research indicates that URM students diverse population.12 Key factors included: the applicants’ educational, financial, are more likely than non-URM students
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to come from low-income families and but several times less than in private Current Comparative Models are therefore disproportionately affected practice employment or ownership.20 The two existing models of alternative by the rising costs of higher education Data from the Robert Wood Johnson providers offer an opportunity to compare and adverse trends in the availability Foundation (RWJF) Dental Pipeline proj- approaches to addressing the access and of financial aid.16 They are less likely to ects indicates that financial factors were diversity challenge. The Alaska DHAT have savings to contribute toward their the major barrier to graduates providing model incorporates most of the program educations or to have families that can dental care to underserved patients. The characteristics that studies indicate are contribute to their educations. Disad- combination of high educational debt key to addressing the access issue, while vantaged students and those with poor and low compensation at community the Minnesota model’s primary feature is credit ratings face difficulty obtaining clinics and from public insurance pro- to increase the supply of practitioners. loans. Minorities are more likely to have grams such as Medicaid are deterrents. The ANTHC has been able to recruit pre-medical school debt. Of 2007 medi- One quote by Judy Stavisky, original socioeconomically disadvantaged minori- cal school matriculants, 59 percent of RWJF program officer, is particularly ties to serve native communities because African-American/black and 43.7 percent the DENTEX training/DHAT program of Hispanic/Latino matriculants had is paid for by the future employer. The debt; in contrast, 68 percent of Asian educational duration program has broken the link between and 64 percent of white matriculants re- exacerbates the debt the cost of training and student debt ported having no debt. This is despite the identified in this and other analyses. fact that 52.6 percent of blacks have their burden and reduces the Furthermore, the program has been suc- 17 schooling funded through scholarships. likelihood of practitioners cessful in retaining these practitioners. URM students are more likely to rely on Keys to the program’s success include: the more expensive unsubsidized loans serving in lower-salaried n Retention — Federal licensure is 18 to fund their educations. Moreover, public health settings. limited to treatment of Alaska natives. students who are married and/or have Applicants have a four‑year employment children generally must borrow in excess contract when they start the program. of the estimated student budget, leaving n Untraditional admission — them with private loans that cannot be telling about the impact of educational Applicants are recruited out of the consolidated following graduation. debt, “It needs to be mentioned, how- population they will serve and through Educational duration exacerbates ever, that the Dental Pipeline program their future employer. the debt burden and reduces the likeli- never had in its original thinking that n No cost/no debt — The employer hood of practitioners serving in lower- students would change their expecta- pays tuition and living expenses. salaried public health settings. DHs tions about where to practice, because so n Support — There is a high degree of graduating from associate degree DH much of that decision is based on debt. cultural consideration, remedial courses, programs rather than the longer bac- Rather, we anticipated that wherever and individual attention during the calaureate programs are more likely to students did end up practicing, they training program. practice in public health.19 This may be might be more accommodating to low- n Flexibility — Training is based on due to having a less expensive educa- income patients and perhaps volunteer competency and students receive addi- tion and therefore not requiring as high at those types of clinics where they tional support and repeat specific a salary. Recruitment of dentists also worked as students. Low-income, non- procedures/training until they pass. continues to be a problem in community URM students were less likely to expect n Preceptorship and ongoing health center (CHC) dental practices. to care for underserved minorities or accreditation — Quality is ensured by Slightly fewer than half of the respond- disabled patients after graduation than limiting the practitioner’s scope of practice ing CHCs (47.8 percent) reported at were URM students.11 Thus, to meet the to the level of competency demonstrated least one vacant dentist position. goal of increased underserved access to at the end of his/her preceptorship. The Mean salaries in CHCs are slightly dental care, this issue must be addressed precepting dentist is typically part of higher than in academic positions for the alternative practitioners as well. the public health structure and/or under
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table 14
Minnesota DT Prerequisites and Program Duration
Minnesota DT BS Minnesota DT MS
Prerequisites 1 year college, prerequisites 3.0 college and BS or BA, prerequisites 3.0 college and high high school GPA. 1,100 SAT/2,400 ACT school GPA. 1,100 SAT/2,400 ACT Training duration 40-month, dental school program 28-month, university-based program
table 15
Comparison of Practitioner Models, Key Criteria for Success
Criteria DT/DHAT ADHP Low cost: Duration and cost of training Low High Access: Entrance requirements for URM Low High Service: Ability to limit practice to target High — limited licensure; recruitment and Low — the model is least economically viable, populations employment practice ensure service even if limited by licensure; a public health setting would be better served by a DT/DHAT Oversight/Quality Assurance: Quality of train- High — ongoing supervision, stringent Moderate — longer duration of training, ing and supervision, functions as a part of the biannual accreditation, training to competency, practices independently of dentist, lower dental team, continued accreditation and licensure limited by individual skill ongoing assurance Scope of practice: broad enough to provide care Yes Yes — broadest
contract with the same tribal organization. Admission standards are high, requiring practitioner and system perspective. The Ongoing support is ensured by having the standardized test scores and a history of shorter training duration should also be DHATs report to a supervising dentist academic success. The scope of practice more successful for deploying diverse who typically was their preceptor. While is no broader; in fact, it may be more and disadvantaged people to practice the practitioners may practice under limited than the DHATs (at the time of in underserved settings. As indicated standing orders, they typically report this study, the scope of procedures taught in table 13, few current DHs meet the daily to a dentist by telephone to preview in the program was not yet available). This URM criteria; thus, the ADHP model cases. They also use a digital camera combination of factors suggests that this must start with high school applicants or more sophisticated teledentistry model is unlikely to have a major impact to increase practitioner diversity. equipment to review and refer cases as in areas with poor access (table 14). needed. The supervising dentist also Conclusion performs the practitioner’s intensive Evaluating Alternative Practitioners Both the dental practice model and biannual accreditation. This is a two-week table 15 provides a quick summary the individual practitioner econom- process during which the practitioner of the key criteria against which po- ics must be sustainable. Based on this works in the supervising dentist’s office. tential practitioner models must be analysis, the DHAT and DT practitioners In contrast, the DT model in Minne- assessed. The DT and DHAT models are cost-effective but will require a direct sota is likely to fail to address a number score most favorably on the majority subsidy similar to that received by current of socioeconomic or diversity issues. The of the criteria: cost, ability to recruit public health clinics, more sustainable programs are relatively high in cost, with and retain URMs, service to the target Denti-Cal procedural reimbursement, university tuition levels. Prerequisites and populations, and quality of care. The or an encounter-based payment. Educa- program duration add to the total expense minor differences in practice scope do tional programs will also require sub- of completing the program. The DT BS not significantly impact the ability to sidies, and these will be lowest for the degree requires one year of college prior to provide needed services to the disad- DHAT and DT. Studies suggest that such entering the 40-month program, and the vantaged communities. Compared to intensive technical training programs DT MS degree is a 28-month program fol- the ADHP, the DT and DHAT models can effectively train quality practitioners lowing completion of a bachelor’s degree. are more economically viable from the and that the shorter duration reduces
62 january 2012 cda journal, vol 40, nº 1
the cost of education to the student references 8. Health Resources and Services Administration, The key 1. Dental hygienist salaries in Alaska, as of Feb. 7, 2010. The ingredient of the national prevention agenda: workforce and society while enabling a more rapid site also indicated that average DH salaries for job postings development. bhpr.hrsa.gov/healthworkforce/reports/keyin- response to the current access issue.21 in Alaska are 11 percent lower than average DH salaries for job gredient.pdf. (Accessed Nov. 28, 2011.) Due to the longer training dura- postings nationwide. indeed.com/salary/q-Dental-Hygienist-l- 9. Bureau of Labor Statistics, Household data, annual averag- Alaska.html. Accessed Nov. 11, 2011. es, occupation, 2008, Table 11: Employed persons by detailed tion, the ADHP was not economically 2. Bureau of Labor Statistics, occupational employment and occupation, sex, race, and Hispanic or Latino ethnicity. bls.gov/ viable in any of the modeled scenarios, wages, 29-2021 Dental Hygienists, May 2008. Based on 2,080 cps/cpsaat11.pdf. Accessed Nov. 11, 2011. including at an encounter-based re- hours and 31-9091 DAs. bls.gov/oes/current/oes292021.htm. 10. Missing Persons: minorities in the health professions, a Accessed Nov. 11, 2011. report of the Sullivan commission on diversity in the health imbursement level of $125. Although 3. Brown LJ, Meskin LH (eds), The Economics of Dental Educa- care work force, September 2004. the educational model could build on tion, ADA, Health Policy Resources Center, Chicago, 2004. 11. RWJF, Pipeline, profession and practice: community-based an existing practitioner pipeline, these 4. Greysen SR, Chen C, Mullan F, A history of medical student dental education, October 2009. debt: observations and implications for future medical educa- 12. Effective strategies for increasing diversity in nursing potential candidates do not have the tion. Acad Med 86(7):840-5, July 2011. programs, AACN Issue Bulletin, December 2001. characteristics to successfully address 5. California Wellness Foundation, On increasing diversity in 13. Markel G, Woolfolk M, Inglehart MR, Feeding the pipeline: the access issue, and, given the econom- the health professions. Reflections 7(2), December 2005. academic skills training for predental students. J Dent Educ 6. 2003 Report of the American Medical Association, medical 72(6):653-61, June 1, 2008. ics of public health practice, they would student section task force on medical student debt, final draft. 14. Disadvantaged student recruitment manual for California be unlikely to choose this setting after 7. The California Smile Survey, An oral health assessment of dental schools, May 2008. incurring additional training expense. california’s kindergarten and third-grade children, February 15. Lopez N, et al, Effective recruitment and retention strate- 2006. gies for underrepresented minority students: perspectives Beyond the economics, policies and approaches must be in place to success- fully recruit and retain practitioners. Creating a pipeline of practitioners specific to the access need and limit- ing their scope of practice ensures that they complete training and are retained in their original profession. Providing reimbursement levels specific to care for the underserved and/or compensation levels in public health settings to keep the practitioner’s debt burden bearable, while limiting the transferability of their license, ensures that the practitioner is retained. It means that there is no option that is more lucrative unless the practitioner wants to re-educate as a DH or dentist. Recruiting practitioners from a cultur- ally and/or socioeconomically diverse background will require additional effort and financial resources to overcome the barriers to higher education that exist in lower socioeconomic strata. However, educating a person from a disadvan- taged community and reinserting him/ her into that community has benefits beyond the effective provision of access to care. This person becomes a role model of achievement in that community and stimulates the area economy.
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from dental students. J Dent Educ 67(10):1107-12, Oct. 1, 2003. to request a printed copy of this article, please 16. Grumbach K, Coffman J, et al, Strategies for improving the contact Anne M. Matthiesen, MHA, MBA, ECG Management diversity of the health professions, the California Endowment, Consultants, Inc., P 206-689-2200 F 206-689-2209, 1111 Third 2003. Ave., Suite 2700 Seattle, Wash., 98101. 17. AAMC, Diversity in medical education: facts and figures 2008, Figures 24 and 26. 18. Council on graduate medical education, 12th report of the council, U.S. Department of Health and Human Services, Public Health Service, Health Resources and Services Administra- tion, Rockville, 1998. hrsa.gov/advisorycommittees/bhprad- visory/cogme/Reports/twelfthreport.pdf. (Accessed Nov. 28, 2011.) 19. Rowe DJ, et al, Educational and career pathways of dental hygienists: comparing graduates of associate and baccalaure- ate degree programs. J Dent Educ 72(4):397-407, April 2008. 20. Bolin KA, Shulman JD, A nationwide survey of dentist recruitment and salaries in community health centers. J Health Care Poor Underserved 15(2):161-9, May 2004. 21. Bolin KA, Assessment of treatment provided by dental health aide therapists in Alaska: a pilot study. J Am Dent Assoc 139(11):1530-5, 2008.
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Are Procedures Performed by Dental Auxiliaries Safe and of Comparable Quality? A Systematic Review
a.p. dasanayake, bds, mph, phd; b.s. brar, ms; s. matta, dds; v. k. ranjan, bds, ms; and r.g. norman, ms, phd
abstract The objective of the current study was to systematically evaluate the existing evidence in relation to the safety, quality, productivity or cost-benefit, and patient satisfaction of the procedures performed by the different groups of dental providers. Due to the diversity of the procedures performed and the outcomes measured, it was not possible to create pooled estimates in a meaningful manner. Therefore, summary results of individual studies are presented and critically evaluated.
authors
A.P. Dasanayake, V. K. Ranjan, bds, ms, is ue to the fact that certain 1885 when Dr. C. Edmund Kells of New bds, mph, phd, is a with the Department of population subgroups have Orleans announced the appointment professor, Department Epidemiology and Health limited access to care, those of the first-known dental assistant.1 In of Epidemiology and Promotion, New York Health Promotion, New University College of who were less trained than 1906, Dr. Alfred C. Fones coined the York University College of Dentistry, New York. dentists started joining the term “dental hygienist.” In 1921, a group Dentistry, New York. Doral health care delivery teams around of “dental nursing students” began a R.G. Norman, ms, phd, the world from the 1920s. These provid- two-year training program sponsored by B.S. Brar, ms, is with is a research associate ers have different levels of training, the New Zealand federal government to the Department of professor, Department Epidemiology and Health of Epidemiology and perform both reversible and irreversible address the high levels of dental disease Promotion, New York Health Promotion, New procedures either independently or under among preadolescent schoolchildren. University College of York University College of direct supervision of a dentist, and are These personnel were called New Zea- Dentistry, New York. Dentistry, New York. given different titles such as the dental land dental nurses/therapists (NZDN/T) nurses or therapists in New Zealand, and provided reversible and irreversible S. Matta, dds, is with acknowledgments the Department of Adult dental hygienists, expanded-function procedures under the general supervision 2 Dentistry, Faculty of This study was funded dental assistants, and dental health aide of a dentist. Later, the “dental nurse” Dental Medicine, Columbia by the California Dental therapists in Alaska. In addition to these title was replaced with “dental therapist.” University, Harlem Association but the content existing providers, there are several cate- This model led to many similar programs Children’s Health Project, of this manuscript is solely gories that have been proposed or that are around the world. As of 2008, there were New York. based on the independent under consideration in the United States. 53 countries utilizing more than 14,000 evaluation of the literature 3 by the authors. None of the Historically, the earliest consider- dental therapists. Historical perspectives authors has any conflicts of ation of adding nondentist members of the development of these auxiliary interests. to the oral health care delivery team in providers in other countries as well as in the United States can be traced back to the United States are well-documented
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in several earlier publications.3-7 More re- tematically evaluate the existing evidence published by November 2010. Details of cently, in a 2010 position paper, American in relation to the safety, quality, produc- this search strategy are given in figure 1. Academy of Pediatric Dentistry (AAPD) tivity or cost-benefit, and patient satisfac- Due to the potential differences in catalog- also reviewed these existing models.8 The tion of the procedures performed by the ing the MeSH headings in earlier publica- models reviewed included the NZDN/T different groups of dental providers. tions, the yield was lower than expected, model, Canadian dental therapist, Alaska and, as such, bibliographies of the articles dental health aide therapist, and the Materials and Methods found were hand-searched, and additional expanded-function dental auxiliaries/ The authors conducted a systematic search strategies were used to obtain the assistants. AAPD concluded that the review using the guidelines given in the remaining pertinent articles. Two pub- quality of care given by these providers is Preferred Reporting Items for Systematic lications that became available after the generally comparable to that of dentists. Reviews and Meta-Analysis: The PRISMA search period were also included in the However, they also raised the ques- Statement.10 The authors’ primary ques- study.11,12 Search filters included human tion of whether these providers have tion was “Are the irreversible procedures studies and were limited to publications the knowledge and experience needed in English language. When the original to determine when to perform which articles were not electronically available, procedures. In addition, models that were authors were contacted. Two independent proposed or that were under consider- a closer look at reviewers (AD and BSB) screened all the ation at the time in the United States the usefulness and the value articles by titles and abstracts to deter- were also reviewed in the above position mine the eligibility. Full-text review of paper. These included the advanced dental of the dental care providers the selected articles was then completed hygiene practitioner (a model proposed other than dentists is now by both reviewers independently and any by the American Association of Den- disagreements were resolved by discus- tal Hygienists), the Minnesota dental warranted more than ever. sion (figure 1). The above search strategy therapist model, and community dental yielded 25 studies published between health coordinator (a model proposed 1950-2010 that had original data and sev- by the American Dental Association). eral review articles relevant to the study. A detailed description of these and performed by any auxiliary provider Upon review of the full texts of the other models are depicted in table 1. category safe compared to the same pro- original articles, five articles were discard- The U.S. Surgeon General’s report, cedures performed by dentists?” Removal ed as having insufficient or inapplicable Oral Health in America: A Report of the or interference with oral structures either data. Data from the resulting 20 original Surgeon General, in 2000 brought to light mechanically or surgically was considered articles were abstracted and summarized the constraints of the U.S. public health irreversible. Due to the limited number in a Summary of Findings Tables using infrastructure in addressing oral health of studies available to answer the above a style similar to the one in Cochrane needs of disadvantaged groups.9 Fur- question, the authors added quality, Handbook for Systematic Reviews of Inter- thermore, as the U.S. population reached productivity or cost-benefit, and patient ventions.13 Study design and the quality 308,745,538 in December 2010, based on satisfaction as secondary outcomes, of the study in terms of sample size, the reported number of 179,594 profes- and also expanded the search to both internal and external validity, biases, and sionally active dentists in the country reversible and irreversible procedures. statistical methods were used to weigh (ADA figure for 2006), the dentist-to- The Cochrane, Medline, Embase, the credibility of the evidence presented. population ratio became approximately and PubMed databases were searched to Due to the diversity of the procedures 1,719 (or 58.2 dentists per 105 people) in identify the published reports that satis- performed and the outcomes measured, it 2010. Within this context, a closer look at fied the study objectives. With the help was impossible to create pooled estimates the usefulness and the value of the dental of two librarians (New York University to quantify the safety, quality, productiv- care providers other than dentists is now Bobst Library and the Waldman Dental ity, and patient satisfaction in a meaning- warranted more than ever. The objective Library), a structured search strategy was ful manner. Therefore, summary results of the current study, therefore, was to sys- developed to capture all relevant articles of individual studies are presented and
66 january 2012 cda journal, vol 40, nº 1 table 1
Auxiliary Providers in Dentistry and Their Training Acronym Full Name (Functions) Country/State Level of Training (within U.S.) ADHP Advanced dental hygiene practitioner. Can practice New workforce 2-year master’s program without the supervision of a dentist, can perform model to improve Licensure required diagnoses and irreversible procedures (e.g., restorations access to oral health and extractions). care in the U.S. CDT Canadian dental therapist (Works in conjunction with Canada 2-year training program licensed dentists under general supervision.) CDHC Community dental health coordinator (Promote oral New workforce 18-month training program health and provide preventive services: screenings, model to improve Certification required fluoride treatments, sealants, temporary fillings and access to oral health simple teeth cleanings until more comprehensive care care in the U.S. from a dentist or a hygienist is available.) DHAT Dental health aide therapist (Provide oral health education, Alaska (New 2-year training program beyond high school. preventive services, diagnosis and treatment of caries, workforce model Certified by the Indian Health Service Board uncomplicated tooth removal, and pulpotomies. They may to improve access also supervise all categories of dental health aides.) to oral health care) EFDA Expanded-function dental assistants/auxiliaries (Work Military/ This class of auxiliary generally includes those who under the direct supervision of a licensed dentist, Armed forces have previously been trained and have experience as a perform various reversible restorative procedures. (U.S.) dental assistant, certified dental assistant, or a dental Specific procedures vary between states.) hygienist. Educational programs for training EFDAs vary from state to state. EFDHA Expanded-function dental health aide (Range of Alaska Specific training programs for each type of EFDHA preventive and restorative procedures that vary have been developed by the Indian Health Service depending on the EFDHA type.) EFDHA I Expanded-function dental health aides I (Assist dentist, Alaska perform prophylaxis, place restorative materials in prepared cavities, and place stainless-steel crowns.) EFDHA II Expanded-function dental health aides II (Perform all Alaska functions of EFDHAs I along with filling simple and complex cavities.) OPA Oral preventive assistant (Preventive services on all Play a role in public Education program with at least 12 months of formal patient types including disease prevention, oral hygiene facilities such training. Certification needed. Curriculum is under instruction, fluoride and sealant application, coronal as community development. Curriculum has both didactic and polishing, and scaling for periodontal type I [gingivitis] health centers and clinical elements. Eligibility: Students who have patients.) schools successfully completed the certified dental assistant exam or 3-month equivalent full-time training. PDHA Primary dental health aide (Provide dental education and Alaska All categories work under varying degrees of preventive services including “toothbrush” prophylaxis, supervision by a dentist. Alaska natives are trained. topical fluoride applications, and oral cancer screenings.) The role of the aide varies, depending on the availability of professionals in the village and the policies of the specific regional native health corporation. PDHA I Primary dental health aide I (Provides education, Alaska prophylaxis, fluoride treatment, and oral cancer exams.) PDHA II Primary dental health aide II (Provides oral hygiene Alaska
instruction, prophylaxis, fluoride treatment, oral cancer exams, radiographs, handle dental emergencies, atraumatic restorative treatment (ART), and assist dentists.) RDA Registered dental assistant U.S. Credentialing provided by the Dental Assisting National Board. Specific training programs vary by state. RDH Registered dental hygienist U.S. Eligible for licensure after graduating from a nationally accredited educational program. Each accredited program is at least two years in length and usually includes general college-level class work before the dental hygiene portion of the curriculum begins, bringing the total class time up to a total of three years.
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Pubmed, Embase and Cochrane Ex: Pubmed Medical subject heading: databases were searched. (“Safety” [MeSH] OR safety OR “Risk Assessment” [MeSH] OR “Efficiency” [MeSH] OR “Effectiveness” OR “Treatment Outcome” [MeSH]) AND (“Dentistry” [MeSH] OR “dental procedure”) AND (“Dental Hygienists” [MeSH] OR “Dental Hygienists” Inclusion criteria: OR “Dental Assistants: [MeSH] OR “Dental Assistants” OR “dental therapist” OR “dental Human subjects
Identification therapists” OR “dental health aide” OR “mid-level Published in English language dental provider” OR “mid-level dental professional”) AND (reversible OR prophyla* OR irreversible OR prevent*)
51 articles were identified Exclusion criteria: Editorials Literature reviews Systematic reviews
S creening Titles and abstracts were reviewed No original data
42 articles were excluded
9 articles were identified
16 additional articles were found by hand search.
Total 25 articles were identified from Included 1950–2010
5 articles were excluded
All the reviewers were calibrated by the Calibration of reviewers principal author (AD).
Each of the reviewers (AD, VRS, and BSB) reviewed all 20 articles. Disagree- ments were resolved by discussion.
Data abstracted using a “Data
Calibration and data abstraction Calibration Abstraction Form.”
figure 1. Literature search and data retrieval calibration and data abstraction.
68 january 2012 cda journal, vol 40, nº 1
table 2
Description of Studies in Relation to Safety: Summary Findings and the Level of Evidence
Study Location Objective Design Study Size Findings p-Value Level of Evidence Lobene, USA: Comparison of infiltration and Prospective 19,849 injection 90% success after Level 2 1979 Boston block anesthesia given by den- attempts 1st attempt; no tal hygienists severe complications Scofield, USA: To collect quantitative data Retrospective 26 dental state No disciplinary Level 3 2005 Texas addressing safety when dental (survey) boards that autho- action against dental hygienist administer local anes- rized dental hygien- hygienists for local thesia ists to administer anesthetic-related local anesthesia. complications 69% responded Bolin, USA: To determine, via a systematic Retrospective 2 Alaskan regional 3% complications Level 3 2008 Alaska chart review, if DHATs practic- (systematic hub clinics and 5 that required a visit ing in rural Alaska communities chart review) DHATs. 640 pro- back to the clinic but were delivering dental care cedures (27% by no group differences within their scope of training in dentists, 34% by an acceptable manner DHAT under direct supervision; 39% by
DHAT under general supervision) RTI, USA: To evaluate implementation of Cross-sectional No. of DHATs = 5; 37 No surgical Level 3 2010 Alaska DHAT program with a particular extractions and 54 complications, one emphasis on assessing care and restorations restoration-related current practice characteristics complication that may be influencing changes in levels of access to care critically evaluated. The level of evidence groups (auxiliaries versus dentists) and to compare the disciplinary actions taken within each study was graded by the where safety is assessed within a mean- against dental hygienists and dentists in experienced lead author (AD) using the ingful time period using objective criteria relation to complications arising from said modified Strength of Recommendation by independent evaluators who are un- procedure over the preceding 10 years.15 Taxonomy (SORT) as published in the aware of the provider type who performed Eighteen (69 percent) boards out of Journal of Evidence-Based Dental Practice.14 the procedures. Instead, what is found 26 approached responded. A majority of in the literature is limited in scope as the responders reported there were no Results well as to a handful of smaller studies. disciplinary actions taken against dental Studies that have addressed each of Local anesthesia can lead to com- hygienists (72 percent) or dentists (67 the four outcomes are shown in tables plications such as paresthesia, trismus, percent) while 5 percent reported disci- 2-5 in relation to the study population, hematoma, and facial nerve paralysis. plinary actions taken against dentists. objective, study design, study size, sum- This procedure is delegated to auxiliary However, this is not a direct comparison mary findings, and the level of evidence. providers in some states. In the 1979 between the safety of administering local Project Rotunda at Forsyth, Lobene et al. anesthesia by auxiliary providers and Safety showed that local anesthesia injections better-trained dentists, and the consider- Surprisingly, very few studies have (infiltration and block) given by dental able rate of nonresponders (28 percent) even made attempts to evaluate the safety hygienists with advanced skills achieved introduce additional bias to the study. of the irreversible procedures performed more than a 90 percent success rate after Bolin did a pilot study to address by the auxiliary providers (table 2). A the first attempt (total attempts=19,849) the safety of the irreversible procedures valid assessment of the safety of proce- with no severe consequences.7 Scofield et performed by Alaska DHATs in 2006.16 dures performed by various providers al. surveyed 26 dental boards that autho- Using randomly selected charts related needs large studies where subjects are rized dental hygienists to administer local to the procedures performed by DHATs randomly assigned to various provider anesthesia in the United States in order that were obtained from five Alaskan
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table 133
DentalDescription Worker of Sbytudies Race, in 2008 Relation9 to Quality: Summary Findings and the Level of Evidence
SPractitionertudy White Location Black or AfricanObjective Asian Hispanic or Latino Total MinoritiesDesign URMs1 Study Size Findings p-Value Level of American Evidence Abramowitz,Dentist 1966 80% USA: IHS 3% To determine12% whether the quality5% of dentistry accomplished21% Experimental;9% nonrandomized; 4 Team Unsatisfactory CL II: NS Level 2 by the teams using EFSAs would be comparable to the quality cross-over, blind clinical and (each with 1 dentist DDS = 28% DH 89% 4% 2% 5% 11% 9% of dentistry performed by the control team that functioned radiographic evaluation of and 2 EFDAs) EFDA = 31% (over 75% overhang and DA 74% 7% according2% to traditional methods17% 26% reversible24% procedures poor marginal adaptation for both) Hammons,1. The Institute 1967 of Medicine committeeUSA: Alabamadefined underrepresentedTo racial evaluate and ethnic the qualitative minorities asperformance African Americans, of restorations Hispanics, andby NativeExperimental; Americans – groups nonrandomized; that Advance Unacceptable: p<0.05 for all Level 2 are both underrepresented and characterized by a group historyEFDAs of deprivation. to that Source:of dental Kelley students WN, Randolph MA, (eds), “Careers in Clinicalblind Research: evaluation Obstacles and undergraduate Unfinished (EFDA = 5.2% 4,990; Opportunities,” Institute of Medicine, National Academy Press, Washington, D.C., 1994. dental students = 20 DS = 7.5% or 2878); EFDAs = 6 Finished (EFDA = 2.3% of 4,979; DS = 1.7% of 1480); Temp. Restoration (EFDA = 1.7% of 289; DS = 11.6% of 189); Matrix Band (EFDA = 3.8% of 2,639; DS = 11.6% of 935);, Rubber Dam (EFDA = 1.7% of 2,395; DS = 9.8% of 1412) Hammons, 1971 USA: Alabama To evaluate the quality of procedures done by EFDAs to that Experimental; randomized; blind Dentists = 8 Unacceptable: Level 2 of dentists evaluation EFDAs = 4 Amalgam (EFDA 1% of 2,282; P<0.05 DDS = 1.8% of 1851; Silicate (EFDA = 3.4% of 799; P<0.05 DDS = 1.8% of 884); Total (EFDA = 1.6% of 3,081; NS DDS = 1.8% of 2735); Temp. Restorations (EFDA = 1% of 264; NS DDS = 0% of 139); Matrix Band (EFDA = 2% of 2,294; P<0.05 DDS = 3.2% of 2,315). Rosenblum, 1971 USA: Minnesota To compare quality and quantity of procedures performed by Experimental; not blinded Dental students = 30; Rubber dam and polishing CL II – EFDA bet- For both p>0.05 Level 3 EFDAs with that of senior dental students EFDAs = 4 ter; polishing class I – dental students better Lotzkar, 1971 USA: Louisville To investigate the feasibility of expanding the functions of Experimental No. of Dentists = 7 To perform a procedure, trained dental Level 3 dental auxiliaries No. of Dental assistance took more time in comparison to Auxiliaries = 22 experienced dentists but their work received Total No. of a quality rating comparable to the dentists procedures = 55,214 Brearley, 1972 USA: Minnesota To compare the quality and quantity of performances of Experimental (RCT) No. of dental All the comparisons either statistically in p = <0.05 Level 2 auxiliaries and dentists; to evaluate the effect on team students = 30 favor of experienced dental auxiliaries or productivity of varying number of dental assistants No. of dental there were no significant differences auxiliary trainees = 4 Abramowitz, 1973 USA To determine the feasibility of dental practice utilizing Experimental (RCT) No of Dentists = 2 The restorations completed by dental p = <0.05 (out of Level 1 auxiliaries with expanded functions quality amount and types No of Dental auxiliaries were of comparable quality to 6, 3 were in favor of service, and economic considerations. assistants = 3 those provided by the dentist. of dental auxilia- expanded duty ries) p>0.05 (out dental auxiliaries = 5 of 6, 3 were equal) Lobene, 1979 USA: Boston Folke, 2004 USA: Minnesota To evaluate the sealant success rate, comparing the provider Retrospective cohort study No. of Dentists = 4 The risk of sealant failure was significantly p<0.05 Level 2 types – dentists, registered dental hygienists, and registered No. of registered lower in sealants placed by RDHs compared dental assistants – while controlling for patient variable dental assistants to those placed by dentists or RDAs (HR = previously shown to alter success rates (RDA) = 8 0.50, p<0.05) Registered dental hygienists (RDH) = 3
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Study Location Objective Design Study Size Findings p-Value Level of Evidence Abramowitz, 1966 USA: IHS To determine whether the quality of dentistry accomplished Experimental; nonrandomized; 4 Team Unsatisfactory CL II: NS Level 2 dental clinics and supervising dentists’ by the teams using EFSAs would be comparable to the quality cross-over, blind clinical and (each with 1 dentist DDS = 28% charts obtained from two regional hub of dentistry performed by the control team that functioned radiographic evaluation of and 2 EFDAs) EFDA = 31% (over 75% overhang and clinics (all procedures done around the according to traditional methods reversible procedures poor marginal adaptation for both) same period and similar geographical Hammons, 1967 USA: Alabama To evaluate the qualitative performance of restorations by Experimental; nonrandomized; Advance Unacceptable: p<0.05 for all Level 2 areas or sampling frames), the safety of EFDAs to that of dental students blind evaluation undergraduate Unfinished (EFDA = 5.2% 4,990; dental students = 20 DS = 7.5% or 2878); the irreversible procedures, such as alloy EFDAs = 6 Finished (EFDA = 2.3% of 4,979; and posterior composite restorations DS = 1.7% of 1480); and extractions, etc., was evaluated. The Temp. Restoration (EFDA = 1.7% of 289; complications that required a visit back DS = 11.6% of 189); to the clinic were less than 3 percent Matrix Band (EFDA = 3.8% of 2,639; DS = 11.6% of 935);, in all cases and there were no reported Rubber Dam (EFDA = 1.7% of 2,395; group differences. Smaller sample size DS = 9.8% of 1412) is a major limitation of this study. Hammons, 1971 USA: Alabama To evaluate the quality of procedures done by EFDAs to that Experimental; randomized; blind Dentists = 8 Unacceptable: Level 2 Five years after the Alaska DHAT of dentists evaluation EFDAs = 4 Amalgam (EFDA 1% of 2,282; P<0.05 program was initiated in 2003, the W.K. DDS = 1.8% of 1851; Kellogg Foundation and other organi- Silicate (EFDA = 3.4% of 799; P<0.05 zations began to objectively evaluate DDS = 1.8% of 884); Total (EFDA = 1.6% of 3,081; NS the program in 2008 and a report was 11 DDS = 1.8% of 2735); released in October 2010. In a cross-sec- Temp. Restorations (EFDA = 1% of 264; NS tional manner, using five villages where DDS = 0% of 139); DHATs were working and some regional Matrix Band (EFDA = 2% of 2,294; P<0.05 hubs, investigators used questionnaires DDS = 3.2% of 2,315). and interviews, direct observations of Rosenblum, 1971 USA: Minnesota To compare quality and quantity of procedures performed by Experimental; not blinded Dental students = 30; Rubber dam and polishing CL II – EFDA bet- For both p>0.05 Level 3 procedures by trained and calibrated EFDAs with that of senior dental students EFDAs = 4 ter; polishing class I – dental students better examiners, and a blind review of the Lotzkar, 1971 USA: Louisville To investigate the feasibility of expanding the functions of Experimental No. of Dentists = 7 To perform a procedure, trained dental Level 3 previous work to evaluate the safety of dental auxiliaries No. of Dental assistance took more time in comparison to Auxiliaries = 22 experienced dentists but their work received the procedures, performance quality, Total No. of a quality rating comparable to the dentists and patient and community satisfaction. procedures = 55,214 A baseline oral health status for future Brearley, 1972 USA: Minnesota To compare the quality and quantity of performances of Experimental (RCT) No. of dental All the comparisons either statistically in p = <0.05 Level 2 comparisons also was established. auxiliaries and dentists; to evaluate the effect on team students = 30 favor of experienced dental auxiliaries or In terms of safety, based on record productivity of varying number of dental assistants No. of dental there were no significant differences auditing, in the above study, it was re- auxiliary trainees = 4 ported that there were no complications Abramowitz, 1973 USA To determine the feasibility of dental practice utilizing Experimental (RCT) No of Dentists = 2 The restorations completed by dental p = <0.05 (out of Level 1 related to 37 extractions (seven done in auxiliaries with expanded functions quality amount and types No of Dental auxiliaries were of comparable quality to 6, 3 were in favor children) but there was one complication of service, and economic considerations. assistants = 3 those provided by the dentist. of dental auxilia- in 54 restorations (25 done in children). expanded duty ries) p>0.05 (out dental auxiliaries = 5 of 6, 3 were equal) The cross-sectional nature, smaller number of DHATs (five), lack of direct Lobene, 1979 USA: Boston comparison of DHAT procedures to that Folke, 2004 USA: Minnesota To evaluate the sealant success rate, comparing the provider Retrospective cohort study No. of Dentists = 4 The risk of sealant failure was significantly p<0.05 Level 2 of dentists, and convenience samples types – dentists, registered dental hygienists, and registered No. of registered lower in sealants placed by RDHs compared dental assistants – while controlling for patient variable dental assistants to those placed by dentists or RDAs (HR = and records, prevented this study from previously shown to alter success rates (RDA) = 8 0.50, p<0.05) drawing robust conclusions regarding Registered dental the true safety and other aspects of the hygienists (RDH) = 3 DHAT program. Authors also cautioned that the findings are not generalizable. Furthermore, DHATs are trained in differ-
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table 134
DentalDescription Worker of Sbytudies Race, in 2008 Relation9 to Quality: Summary Findings and the Level of Evidence
Study Location Objective Design Study Size Findings p Level of Evidence Baird, 1963 Royal Canadian Dental To establish whether clinical technicians (dental hygienists) Observational No. of dentists = 1 DH addition increased the team productivity Level 3 Corps can be trained economically undertake additional responsibili- No. of dental by 61.7%. Waiting period decreased from ties and employed effectively under conditions existing in the auxiliaries = 3 6-8 weeks to 2-3 weeks. Operation cost average clinic of the Royal Canadian Dental Corps increased by 33.9% (DH salary). Sutcliffe, 1969 UK To assess productivity of a dentist working with an auxiliary Retrospective chart review No. of dentists = 1; 64% increase in patients seen/day; 50% Level 3 Auxiliaries = 1 increase in procedures/day; 79% more restorations and 29% more extractions Lotzkar, 1971 (b) USA: Louisville To assess the performance of dentists who worked as head Experimental; nonrandom; No. of dentists = 6 110%-133% productivity over baseline with Level 3 of dental teams with varying number of EFDAs nonblind evaluation No. of dental 1:4 dentist:EFDA ratio. 62%-84% increase auxiliaries = 15 with 1:3 ratio Total No. of patients = 6,400 Brearley, 1972 USA: Minnesota To compare the quality and quantity of performances of Experimental (RCT) No. of dental 33% increase in productivity with addition P>0.05 Level 2 auxiliaries and dentists; to evaluate the effect on team students = 30 of expanded-duty dental auxiliaries. productivity of varying number of dental assistants No. of dental Addition of a second dental assistant auxiliary increased 18.5% productivity trainees = 4 Abramowitz, 1973 USA To determine the feasibility of utilizing auxiliaries with Experimental (RCT) No. of dentists = 2 The efficient use of EFDAs resulted in Level 2 expanded functions, quality, amount and types of service, No. of dental decreased fees, increased net income or a and economic considerations assistants = 3 combination of both EFDAs = 5
Redig, 1974 USA: San Francisco To determine whether the performance of more routine Experimental No. of dentists = 10 The use of EFDAs was economically feasible Level 3 reversible dental procedures by dental auxiliaries would No. of dental and permitted the dentists to deliver more permit the dentist to spend his time on more complex auxiliaries = 6 dental services procedures Harris, 2004 UK: Liverpool To describe the type of patients seen and work undertaken Observational No. of dentists = 13 The dental therapists may play an important P>0.05 Level 3 by dental therapists employed in four personal dental service (prospective cohort) No. of dental role within the dental team, particularly in practices and to report their cost effectiveness therapists = 4 relation to prevention Brown, 2005 USA: Colorado To analyze the economic aspects of unsupervised private Observational study No. of dentists The impact of unsupervised dental hygienist Level 3 hygiene practice and its impact on access to care in Colorado provided practices is limited and their economic data = 279 viability is questionable No. of dental hygienists = 20
ent programs (i.e., New Zealand versus work records. During the study, each two evaluators disagreed with the qual- United States) and this needs to be taken team performed more than 1,500 restora- ity of the restorations 25 percent of the into consideration in future evaluations. tions while changing the experimental/ time. In an extension of this study, the control group assignment (crossover) same authors concluded that EFDAs were Quality in the middle of the study. Using two able to provide restorations of accept- In an IHS experimental study of independent and double-blind evaluators, able quality.18 The superior study design, crossover design, Abramowitz evaluated who used visual as well as radiographic considerable sample size, and the direct the quality of randomly selected class 2 examinations, the investigator reported double-blind clinical and radiographic amalgam restorations done by four teams that the unsatisfactory class II amalgam evaluation added credibility to this study. of clinicians17 (table 3). Each team had a restorations done by dentists (28 percent) In another study, Hammons et al. dentist and two expanded-function dental was similar to that of EFDAs (31 percent; compared hundreds of reversible proce- auxiliaries (EFDA). To be eligible for the p>0.05). Close to 45 percent of the above dures done by six carefully selected EFDAs study, each team had to have at least one unsatisfactory restorations were due to to that of advanced dental students.4 In year of clinical experience and comparable poor marginal adaptation. However, the this nonrandomized experimental study,
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Study Location Objective Design Study Size Findings p Level of Evidence Baird, 1963 Royal Canadian Dental To establish whether clinical technicians (dental hygienists) Observational No. of dentists = 1 DH addition increased the team productivity Level 3 Corps can be trained economically undertake additional responsibili- No. of dental by 61.7%. Waiting period decreased from 100 reversible procedures were randomly ties and employed effectively under conditions existing in the auxiliaries = 3 6-8 weeks to 2-3 weeks. Operation cost allocated to them and the quality was average clinic of the Royal Canadian Dental Corps increased by 33.9% (DH salary). blindly evaluated using pretested criteria Sutcliffe, 1969 UK To assess productivity of a dentist working with an auxiliary Retrospective chart review No. of dentists = 1; 64% increase in patients seen/day; 50% Level 3 as before. Unacceptable finished amalgam Auxiliaries = 1 increase in procedures/day; 79% more restorations and matrix band placement restorations and 29% more extractions were significantly lower among the EFDAs Lotzkar, 1971 (b) USA: Louisville To assess the performance of dentists who worked as head Experimental; nonrandom; No. of dentists = 6 110%-133% productivity over baseline with Level 3 while the dentists had a lower propor- of dental teams with varying number of EFDAs nonblind evaluation No. of dental 1:4 dentist:EFDA ratio. 62%-84% increase tion of unacceptable finished silicate auxiliaries = 15 with 1:3 ratio fillings. In a similar manner, Rosenblum Total No. of patients = 6,400 compared 20 teams (each comprising of a senior dental student, an EFDA, and Brearley, 1972 USA: Minnesota To compare the quality and quantity of performances of Experimental (RCT) No. of dental 33% increase in productivity with addition P>0.05 Level 2 auxiliaries and dentists; to evaluate the effect on team students = 30 of expanded-duty dental auxiliaries. an assistant) who treated 363 patients productivity of varying number of dental assistants No. of dental Addition of a second dental assistant over nine months to 10 teams (each auxiliary increased 18.5% productivity only had a senior student and an as- trainees = 4 sistant) who treated 118 patients.20 Abramowitz, 1973 USA To determine the feasibility of utilizing auxiliaries with Experimental (RCT) No. of dentists = 2 The efficient use of EFDAs resulted in Level 2 Patients were randomly allocated expanded functions, quality, amount and types of service, No. of dental decreased fees, increased net income or a to experimental and control groups. and economic considerations assistants = 3 combination of both Reversible procedures such as rubber EFDAs = 5 dam use and polishing class II restora- Redig, 1974 USA: San Francisco To determine whether the performance of more routine Experimental No. of dentists = 10 The use of EFDAs was economically feasible Level 3 tions were statistically significantly reversible dental procedures by dental auxiliaries would No. of dental and permitted the dentists to deliver more better in EFDAs compared to dental permit the dentist to spend his time on more complex auxiliaries = 6 dental services procedures students in this study. However, the procedures were evaluated by unblinded Harris, 2004 UK: Liverpool To describe the type of patients seen and work undertaken Observational No. of dentists = 13 The dental therapists may play an important P>0.05 Level 3 by dental therapists employed in four personal dental service (prospective cohort) No. of dental role within the dental team, particularly in and uncalibrated evaluators. By adding practices and to report their cost effectiveness therapists = 4 relation to prevention a group of newly trained EFDAs to the Brown, 2005 USA: Colorado To analyze the economic aspects of unsupervised private Observational study No. of dentists The impact of unsupervised dental hygienist Level 3 teams, these investigators also showed hygiene practice and its impact on access to care in Colorado provided practices is limited and their economic that after 10 weeks of clinical experience, data = 279 viability is questionable quality of procedures of newly trained No. of dental EFDAs was similar to that of more hygienists = 20 experienced EFDAs and both groups remained significantly superior to the dental students in performing several they independently evaluated a random matrix band and rubber dam placing were reversible procedures.21 In this study, sample of procedures selected from also significantly higher among the dental more than 90 percent of the participat- each group using pretested criteria. The students. These findings are also of little ing dental students favored the expan- procedures compared included insert- value due to small study size as well as sion of the role of dental assistants. ing and finishing amalgam and silicate the lack of direct comparisons of EFDA In an elaborate and methodologi- restorations, temporary restorations, procedures to that of trained dentists. cally sound NIH sponsored 5.5-year placing matrix bands, and placing rubber Once again, there were no irreversible study, Lotzkar et al. trained 32 assistants dams. Unacceptable unfinished amalgam procedures assigned to the EFDAs. to perform expanded-duty reversible and silicate restorations were signifi- Using four of the same EFDAs, Ham- functions and independently evaluated cantly lower in the EFDA group. Finished mons et al. extended the above study their performance and found out that amalgam restorations were of equal by comparing their performance on the although they required more time to quality while the silicate restorations were same irreversible procedures to that of perform these procedures compared to significantly better among the students. eight dentists (six private practice and dentists; 53 percent to 93 percent of their Unacceptable temporary restorations and two university instructors).19 More than procedures met the required standard.22
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table 5
DentalDescription Worker of Sbytudies Race, in 2008 Relation9 to Patient Satisfaction: Summary Findings and the Level of Evidence
Study Location Objective Design Study Size Findings p Level of Evidence Sisty, 1974 USA: Iowa To determine whether patients accepted expanded, intraoral Experimental (RCT) No. of dental Dental hygiene students received higher rat- p>0.05 Level = 3 procedures performed by dental hygiene students students = 30 ings than the dental students on preventive No. of dental periodontal functions hygiene students = 12 Holst, 1994 Sweden To evaluate the dental assistant selection of caries risk Prospective cohort No. of dental The % of children with no caries in the test Level = 3 children up to age 3 by comparing dental health variables in assistants = 2 clinic was more than whole country and time 4-year-olds in the test clinic with those for the whole country spent in clinic was less. But the % was same for >=4 & >=8 deft Gutkowski, 2007 USA: California To evaluate the role of clinical and administrative staff in Observational study The team approach to caries management by Level = 3 maintaining a practice with a focus on disease prevention and risk assessment is integral to the disease in management the incidence and prevalence of dental caries among various populations Sun, 2010 UK: Liverpool To investigate whether there were any differences in patient Observational study No. of dentists There is a difference in patient satisfaction p<0.001 Level = 3 satisfaction after a visit to a therapist compared to a visit to = 42 between patients reporting on care provided a dentist No. of dental by a dental therapist compared to a dentist therapists = 11 RTI, 2010 USA: Alaska To evaluate implementation of DHAT program with a particu- Cross-sectional No. of DHAT = 5 The five therapists who were included were Level = 3 lar emphasis on quality, safety, and patient satisfaction performing well, operating safely & appro- priately within the defined scope of practice. The patients were generally very satisfied with the care they received.
In phase 3 of the same study, they com- performed cavity preparation, restora- dental sealants. Using 3,194 first molar pared EFDA procedures to that of seven tions, and local anesthesia (infiltration sealants (in 810 subjects) done in a private dentists and found out that 83 percent and block). Although some sample practice setting in Minnesota where the of the EFDA phase 3 procedures met the sizes were small, the performance of operators (four dentists, three hygienists, required standard, a proportion similar hygienists was blindly and repeatedly and 10 dental assistants) used identical to that of the dentists during phase 1.23 evaluated both internally and exter- protocols and four-handed dentistry, Folke Although the numbers of assistants nally while also evaluating the patient et al. conducted a 10-year retrospective and dentists used in the study are still satisfaction. Dental hygienists (N=19) follow-up study to evaluate the factors small, the independent evaluation of the received acceptable mean quality points related to sealant failure.24 Mean survival outcomes adds credibility to this study. (10.2) that were comparable to what of sealants in the dentist group was 3.45 In 1949, the Forsyth experiment, a was given to 15 dentists (10.6; a score years, dental assistants, 3.65, and dental five-year program where dental hygien- of 9 was the acceptable value) for cavity hygienists, 7.7 (p<0.05). After controlling ists were trained to do fillings, was preparation. Amalgam restorations also for the other potential factors related started but was abandoned after one received higher quality points that were to sealant failure, they showed that the year due to political and other reasons comparable to dentists (12.9 versus 12.5). risk of sealant failure was significantly at the time. In 1972, the project restarted Interestingly, radiographic examination lower for dental hygienists compared to in a refined manner as Project Rotunda, of fillings done by the hygienists only dentists and dental assistants (HR=0.5; but was again terminated in 1972. In showed overhangs in 5 percent of the 528 p<0.05). It should be noted that the 1975, the project report came out that fillings. This value was much smaller than sealants were placed by a smaller num- also met with sharp criticisms that led the value of 24.9 percent obtained from ber of providers in this study as well. to a Blue Ribbon Commission Report in 556 fillings done by dentists at baseline. Bolin evaluated 640 procedures done on 1976.7 However, in this elaborate study, Another procedure that is delegated 406 subjects (27 percent done by dentists, dental hygienists with advanced skills to several types of auxiliary providers is 34 percent by DHAT under direct super-
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Study Location Objective Design Study Size Findings p Level of Evidence Sisty, 1974 USA: Iowa To determine whether patients accepted expanded, intraoral Experimental (RCT) No. of dental Dental hygiene students received higher rat- p>0.05 Level = 3 DHATs), and much lower than that in New procedures performed by dental hygiene students students = 30 ings than the dental students on preventive Zealand where dental therapists have been No. of dental periodontal functions around for more than 90 years, further hygiene 11 students = 12 confirming the limitations of this study. Holst, 1994 Sweden To evaluate the dental assistant selection of caries risk Prospective cohort No. of dental The % of children with no caries in the test Level = 3 children up to age 3 by comparing dental health variables in assistants = 2 clinic was more than whole country and time Productivity (Cost-Benefit) 4-year-olds in the test clinic with those for the whole country spent in clinic was less. But the % was same In a small observational study, Baird for >=4 & >=8 deft et al. tried to establish whether clinical Gutkowski, 2007 USA: California To evaluate the role of clinical and administrative staff in Observational study The team approach to caries management by Level = 3 technicians (dental hygienists) can be maintaining a practice with a focus on disease prevention and risk assessment is integral to the disease in trained economically to undertake ad- management the incidence and prevalence of dental caries ditional responsibilities and be employed among various populations effectively under conditions existing in Sun, 2010 UK: Liverpool To investigate whether there were any differences in patient Observational study No. of dentists There is a difference in patient satisfaction p<0.001 Level = 3 the average clinics of the Royal Canadian satisfaction after a visit to a therapist compared to a visit to = 42 between patients reporting on care provided Dental Corps25 (table 4). Using one den- a dentist No. of dental by a dental therapist compared to a dentist tist and three hygienists with 3.5 years of therapists = 11 experience and additional training, they RTI, 2010 USA: Alaska To evaluate implementation of DHAT program with a particu- Cross-sectional No. of DHAT = 5 The five therapists who were included were Level = 3 showed that the addition of the hygienist lar emphasis on quality, safety, and patient satisfaction performing well, operating safely & appro- priately within the defined scope of practice. increased the team productivity by 61.7 The patients were generally very satisfied percent while the waiting period de- with the care they received. creased from six to eight weeks to two to three weeks. This step only increased the cost in terms of salary to the operation by 33.9 percent. While the results had certain vision, and 39 percent by DHAT under have partially led to the observed results. merits, use of only one dentist and three general supervision) using the applicable Within the limitations of the Kel- dental hygienists and the restriction of IHS quality assessment criteria.16 DHATs logg report previously identified under procedures to reversible procedures were treated significantly younger patients (mean the safety section of this paper, in terms major limitations of this early study. age=16.9 years) compared to dentists (mean of quality of the DHAT procedures, the In a retrospective review of day age=24 years; p<0.02) but the types of study indicated that the deficiencies in books obtained from a clinic where the procedures are reported to be similar except preparation and restoration of composite clinician worked the whole day, Sut- for more stainless-steel crowns done by restorations (total N=15 preparations and cliffe evaluated the increase in baseline DHATs.16 There was a deficiency in adequate 73 restorations) were similar between clinic productivity (more than 167 radiographs for younger children treated by DHATs and dentists (12 percent-15 working days) when an auxiliary was DHATs. The use of just one evaluator has percent).11 However, the proportion of added to the dentist-assistant team and minimized the examiner variability in this deficient amalgam restorations was smaller observed for another 114 subsequent pilot study but the DHAT program was at its among DHATs (12 percent) compared to days.26 While it is not surprising to infancy at the time of the study (6 months dentists (22 percent). Although the oral see that two operators can see more of age) thus restricting the study size. A health impact profile (OHIP-14) is not a patients and do more procedures com- chart review has certain limitations and true direct measure of the quality of DHAT pared to just one operator, there was a some data were restricted to census surveys procedures, based on subjects experienc- 64 percent increase in the number of rather than actual chart reviews, further ing at least one impact factor (e.g., painful patients seen/day and a 50 percent in- compromising the validity of the findings. aching mouth) either “fairly often” or “very crease in procedures done/day (79 per- Chart selection may also have favored often,” the OHIP prevalence for Alaska was cent more restorations and 29 percent dentists due to logistics. Furthermore, reported to be 19.3 percent in this study, a more extractions). A dentist’s perfor- the age differences in the patient groups prevalence that is higher than that in the mance was not diminished as a result of treated by the two types of providers may United States (where there are no other having to supervise the auxiliary either.
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Although irreversible procedures were able to other settings and populations. dental hygiene (EFDH) students (N=12) also included in the study, the investiga- In a purely theoretical exercise, the and used 338 patient surveys related to tor missed the opportunity to make direct PEW Center claimed that hiring an allied periodontal procedures done by EFDHs comparisons of the safety and quality of provider can make business sense for var- and 319 surveys related to the same pro- these procedures done by the auxiliaries. ious private dental practices by increasing cedures done by the dental students. They Rosenblum’s comparison of EFDAs to the clinic productivity while providing concluded that the patients were equally senior dental students also indicated care to low-income Americans who do or more satisfied with the EFDH students. a 40 percent increase in productivity not currently have access to such care.12 When the operative procedures were (2.6 procedure per half day without the By adding auxiliary providers to solo pe- compared using 273 surveys related to EFDA in the student and assistant team diatric and general practices and a small EFDH procedures and 211 related to dental compared to 4.3 when an EFDA is added group practice, they extrapolated more student procedures, similar results were to the team).20 Lotzkar et al. also showed than 50 percent profit and productivity seen. Inclusion of irreversible procedures an increased productivity of dental teams impact in solo practices and close to 20 such as cavity preparation and surgical when EFDAs are added to the team, as management of periodontal soft tissues has been shown by Abramowitz.18,22,23 Us- and the masking of the patient to the op- ing four private dental offices in the San erator status increased the quality of this Francisco Bay Area and six EFDAs, Redig a dentist’s study. Project Rotunda also showed that et al. extensively evaluated the productiv- performance was not 99.1 percent of the 1,200 patients surveyed ity aspect of adding auxiliary providers were satisfied with the procedures per- to private dental offices.27 By evaluating diminished as a result formed by the advanced-skills hygienists.7 19,034 reversible procedures performed of having to supervise In a 2010 study, Sun et al. compared in these offices (40 percent were related patient satisfaction related to the proce- to placing and finishing permanent the auxiliary either. dures performed by dental therapists to restorations), they demonstrated a net that of dentists in eight practices in the area increase in the number of patient visits northwest of England.30 They used a 10-item per eight hours during the 12-month overall patient satisfaction scale and three study period compared to the baseline. percent impact in the small group practice subscale outcomes (related to communica- Although the quality or the safety of without adding Medicaid patients to the tion, understanding, and competence) to the procedures was not independently mix. The impact was much lower, yet was survey 240 consecutive patients who were evaluated, the authors concluded that still positive, when the assumption was treated by therapists and 400 treated by the use of EFDAs in private settings is made that the practice served 20 percent dentists. They concluded that the overall not only feasible but also allows dentists Medicaid patients. Although this is a patient satisfaction as well as subscale to provide more services in less time. theoretical exercise, the authors included satisfaction were significantly higher for In a United Kingdom study done by this here because similar evaluations can the therapists (p<0.001). These differences Harris et al., the cost-effectiveness of add- be done using actual data from various remained significant after controlling for ing a dental therapist to four personal den- practices using well-designed studies. selected covariates. Limitations of this tal services was evaluated.28 Based on day study are the much lower response rates of sheets related to 30 consecutive sessions Patient Satisfaction patients treated by therapists (54.2 percent) kept by therapists and 20 sessions of den- Patient-reported outcomes are consid- compared to the response rate for dentists tists, they observed the therapists to see ered a measure of quality of care pro- (75.3 percent), which may have biased the more children and to perform more seal- vided. As Lotzkar et al. showed, Sisty et results, nonrandom sampling, and the ants, but the gross fees and patient charges al. also showed an acceptable patient sat- investigators inability to control for the generated by the dental therapist in all four isfaction of the procedures performed by types of procedures performed (a factor practices failed to cover the cost of salary the auxiliary providers22,23,29 (table 5).They directly related to patient satisfaction). and related overhead. However, the results compared junior dental students (N=30) Furthermore, these findings may not even of this small study may not be generaliz- and randomly selected expanded-function be generalizable to the United Kingdom.
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The Kellogg Report also addressed dures that are not authorized, they may the rules and regulations governing the the patient and caregiver satisfaction perform irreversible procedures without practices. Unfortunately, such studies are related to DHATs in Alaska.11 Authors adequate supervision thus compromising not available in the literature most likely reported that the caregivers rated their the patient safety, and perhaps no care due to obvious logistical challenges. DHATs with a mean rating score of 8.3 may be better than providing potentially The authors conducted a systematic out of a best rating of 10. Limitations harmful care. Leaving all these specula- review of the available literature using stan- of the Kellogg study identified earlier tions behind, one should critically evalu- dard methodology to obtain unbiased esti- apply to this observation as well. ate the safety, quality, productivity, as mates of the safety, quality, productivity, and well as the patient satisfaction related to patient satisfaction related to the procedures Discussion the procedures that have been performed performed by the auxiliary providers. While The supply or availability of dentists by various providers over the years. there were no studies with the highest level is constrained at least in some geographic One way to evaluate the auxiliary of evidence to demonstrate the true safety locations and in low-income and minority providers is to conduct valid compari- of various procedures performed by these groups while the need to contain cost is providers compared to dentists, a smaller escalating. In the medical profession, this number of studies have made attempts to same issue was addressed by the nurse- compare the safety of local anesthesia and doctor substitution or by adding physician final evaluations some irreversible procedures.7,11,15,16 These assistants. In a Cochrane review, appropri- should be performed by studies are subjected to inadequate power, ately trained nurses were shown to produce biased subject selection, and less-than- as high quality care as primary care provid- masked evaluators adequate comparisons as shown within ers and achieved as good health outcomes using valid and tested the results section related to each study. for patients.31 Although the above review There were numerous experimental has the limitation of not having enough evaluation criteria. and observational studies that addressed studies with adequate power, the medical the quality of the reversible as well as profession continues to use nurse practi- irreversible procedures (table 3). Some of tioners and physician assistants. This same these studies were of high quality including approach of delegating at least certain func- sons of the procedures performed by experimental studies funded by the NIH, tions to auxiliary providers within dentistry them to that of dentists. Such compari- but these early studies were only focusing goes back to the 1920.2 ADA House of Del- sons should be done using randomized on the quality of the reversible procedures, egates recommended that research be car- control trials (RCTs) with sufficient again as shown within the “Results” section. ried out to identify the functions that can statistical power that achieves base- In addition, a large retrospective study has be delegated without putting patients at risk line comparability in terms of various convincingly shown better survival of seal- as early as in 1962 (see Abramowitz et al.).18 confounding factors that might influence ants placed by dental hygienists.24 However, The general notion at the time was the results. Final evaluations should be the quality of the irreversible procedures that diagnosis and treatment plan- performed by masked evaluators using is at best inconclusive due to numerous ning, prescriptions, surgical procedures, valid and tested evaluation criteria. This methodological deficiencies of these studies and other procedures that required design is challenging as not all auxiliary as shown within the “Results” section. advance skills should not be delegated. providers can perform all the procedures Several studies have addressed the Judging from the letters to the editors that are performed by dentists. Disease, cost-benefit of adding the auxiliary provid- and position papers, there are numer- as well as patient characteristics and ers to practices (table 4). As expected, ous arguments made against the use practice characteristics, may also influ- most of these studies show evidence for of auxiliary providers in dentistry. ence the outcomes. As such, there is a increase productivity and a reasonable Among these arguments are the no- need to use stratified randomization us- cost-benefit ratio, which goes well with tions that the patients will receive second- ing the procedure types, disease, patient, some of the theoretical projections.12 class care from the auxiliary providers, and practice characteristics when allocat- Relative merits of each of these studies are these providers may perform proce- ing subjects to various providers within also shown within the “Results” section.
january 2012 77 systematic study
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Patient-reported outcomes and their Conclusions health aide therapists in Alaska: a pilot study. J Am Dent As- satisfaction are important considerations in Available evidence is sufficient to a soc 139(11):1530-5; discussion 1536-9, November 2008. 17. Abramowitz J, Expanded functions for dental assistants: evaluating health care or other services. Evi- larger extent to conclude that the auxiliary preliminary study. J Am Dent Assoc 72:386-91, 1966. dence that indicates the patients are general- providers are capable of providing safe and 18. Abramowitz J, Berg LE, A four-year study of the utilization ly satisfied with the performance of the aux- high quality reversible procedures while of dental assistants with expanded functions. J Am Dent Assoc 87(3):623-35, September 1973. iliary providers (table 5) is based on limited enhancing the productivity of the practices. 19. Hammons PE, Jamison HC, Wilson LL, Quality of service observations and may not be generalizable Patients have generally shown satisfac- provided by dental therapists in an experimental program to populations other than the study groups. tion with their performance. However, at the University of Alabama. J Am Dent Assoc 82(5):1060-6, May 1971. the evidence in relation to the irreversible 20. Rosenblum FN, Experimental pedodontic auxiliary training Limitations procedures related outcomes is insufficient program. J Am Dent Assoc 82(5):1082-9, May 1971. One of the limitations of the authors’ and there is a need for further investiga- 21. Brearley LJ, Rosenblum FN, Two-year evaluation of auxiliaries trained in expanded duties. J Am Dent Assoc study is the fact they restricted the studies tions using adequately powered and well- 84(3):600-10, March 1972. to the English language. They also could designed randomized control trials and 22. Lotzkar S, Johnson DW, Thompson MB, Experimental not create summary or pooled estimates other large observational studies. program in expanded functions for dental assistants: phase 1 base line and phase 2 training. J Am Dent Assoc 82(1):101-22, to demonstrate the overall safety, quality, January 1971. cost-effectiveness, and patient satisfac- references 23. Lotzkar S, Johnson DW, Thompson MB, Experimental 1. Torres HO, Ehrlich A, Modern dental assisting. Philadelphia, tion of the auxiliary providers due to program in expanded functions for dental assistants: phase 3 W.B. Saunders Company, 1976. experiment with dental teams. J Am Dent Assoc 82(5):1067-81, the diverse nature of the procedures 2. Dunning JM, Dunning N, An international look at school- May 1971. performed and the outcomes measured. based children’s dental services. Am J Public Health 24. Folke BD, Walton JL, Feigal RJ, Occlusal sealant success 68(7):664-8, July 1978. over 10 years in a private practice: comparing longevity of 3. Nash DA, Friedman JW, et al, Dental therapists: a global sealants placed by dentists, hygienists, and assistants. Pedi- Future studies perspective. Int Dent J 58(2):61-70, April 2008. atr Dent 26(5):426-32, September-October 2004. As indicated earlier, there definitely 4. Hammons PE, Jamison HC, Expanded functions for dental 25. Baird KM, Pilot study on advance training and employment auxiliaries. J Am Dent Assoc 75(3):658-72, September 1967. is a need for a fully powered randomized of auxiliary dental personnel in the Royal Canadian Dental 5. Lotzkar S, Johnson DW, Thompson MB, Experimental Corps: final report. J Can Dent Assoc 29(12):778-87, 1963. controlled trial to obtain valid estimates program in expanded functions for dental assistants: phase I 26. Sutcliffe P, Dental auxiliaries: a method of measuring their related to safety, quality, cost-benefit, as baseline and phase II training. J Am Dent Assoc 82:101-22, 1971. clinical usefulness. Br Dent J 126(9):418-20, May 6, 1969. 6. Berman DS, Utilization of the dental auxiliary — school well as patient satisfaction related to the 27. Redig D, Snyder M, et al, Expanded study dental auxiliaries dental nurse. Int Dent J 19(1):24-40, March 1969. in four private dental offices: the first year’s experience. J Am procedures performed by the auxiliary den- 7. Lobene R, The Forsyth experiment: an alternative system Dent Assoc 88(5):969-84, May 1974. tal providers. Given that the NIH has three for dental care. Cambridge, Mass., Harvard University Press, 28. Harris R, Burnside G, The role of dental therapists working 1979. practice-based research networks (PBRN) in four personal dental service pilots: type of patients seen, 8. AAPD, American Academy of Pediatric Dentistry analysis work undertaken and cost-effectiveness within the context that are already in place, as a prelude to and policy recommendations concerning auxiliary dental of the dental practice. Br Dent J 197(8):491-6, discussion 477, this RCT, valid observational studies can be providers. Pediatr Dent 32:21-6, 2010. Oct. 23, 2004. 9. Oral health in America: a report of the surgeon general. J performed within these PBRNs to generate 29. Sisty NL, Henderson WG, A comparative study of patient Calif Dent Assoc 28(9):685-95, September 2000. evaluations of dental treatment performed by dental and sufficient data to design a fully powered 10. Moher D, Liberati A, et al, Reprint — preferred reporting expanded-function dental hygiene students. J Am Dent Assoc RCT and to test the feasibility of such a RCT items for systematic reviews and meta-analyses: the PRISMA 88(5):985-96, May 1974. statement. Phys Ther 89(9):873-80, September 2009. before designing and implementing RCTs 30. Sun N, Burnside G, Harris R, Patient satisfaction with care 11. RTI, Evaluation of the dental health aide therapist by dental therapists. Br Dent J 208:1-7, 2010. within the same PBRNs or other settings. A workforce model in Alaska. Research Triangle Park: RTI 31. Laurant M, Reeves D, et al, Substitution of doctors multicenter international collaboration may International. 0211727.000.001, 2010. by nurses in primary care. Cochrane Database Syst Rev 12. PEW, It takes a team. Washington, DC, PEW Center on the (2):CD001271, 2005. further enhance the value and the useful- States, 2010. ness of the study as it then can be taken 13. Higgins JPT, Green S, Cochrane handbook for systematic to request a printed copy of this article, please contact into account the baseline differences in reviews of interventions version 5.0.2: the Cochrane collabo- A.P. Dasanayake, BDS, MPH, PhD, Department of Epidemiol- ration, 2009. cochrane-handbook.org. (Accessed Nov. 3, 2011.) health care systems, population and disease ogy and Health Promotion, New York University College of 14. Newman MG, Weyant R, Hujoel P, JEBDP improves grading Dentistry, 250, Park Ave., South, Room 646, New York, N.Y., characteristics, types of providers and their system and adopts strength of recommendation taxonomy 10003. level of training etc. Such a study may ap- grading (SORT) for guidelines and systematic reviews. J Evid Based Dent Pract 7(4):147-50, December 2007. pear to be too ambitious at the outset, but it 15. Scofield JC, Gutmann ME, et al, Disciplinary actions associ- can be done with careful planning if there is ated with the administration of local anesthetics against den- sufficient interest and adequate resources. tists and dental hygienists. J Dent Hyg 79(1):8, winter 2005. 16. Bolin KA, Assessment of treatment provided by dental
78 january 2012 Endorsed_Journal Jan_2012_REV1.pdf 1 12/23/11 10:09 AM
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LOS ANGELES COUNTY BELL - Long established practice located one story bldg in busy shopping center. Absentee owner. Proj. approx.$442K for 2011.ID #4085. BEVERLY HILLS - Fee for service practice located in a multi story professional building with great window views to the city. ID#4081 ENCINO - Leasehold & Equip Only! - Corner location w/ good window views. A great starter opportunity / 3 spacious eq. ops. ID#3971. GLENDORA - Long established general practice with 44 years of goodwill located in 2 story building.4 ops. Net of $404K ID #3041 INGLEWOOD - Long established Turnkey office in single standing bldg. w/ 5 ops. Has great street visibility and signage.ID# 4095 MONTEBELLO - Located in a free standing building w/ over 25 yrs of gdwll. Great street visibility, signage and foot traffic. ID #4051. PALOS VERDES ESTATES (GP Group Solo) - 40 years of gdwll in a 3 story prestigious bldg w/ ocean view. Fee for service. ID #4059. WOODLAND HILLS - Well equipped Pedo office with 3 chairs in open bay. 31 yrs of goodwill. NET OF $318K on 4 days/wk. ID#3661.
ORANGE COUNTY ANAHEIM - Leasehold & Equip Only! - In colonial style medical plaza w/ large French windows near Medical Cntr. 4 ops. ID #4061. ANAHEIM - Multi specialty office located in single story strip mall on busy intersection. 30 yrs of goodwill. 6 ops. NET $260K. #4105. FULLERTON - Well established off in 1 story bldg w/ 10 ops, 3 chairs in open bay in 5,215 sq. ft. Proj. approx $594K for 2011.#41.03. GARDEN GROVE - Turnkey practice w/ over 20 years of gdwll located in one story free standing building w/ ample parking. ID #3988. HUNTINGTON BEACH - Leasehold, Equip & Some Charts! Recently remodeled off. located on major blvd w/ heavy traffic flow #4111. IRVINE - Located in busy shopping cntr w/ lots of foot traffic. Modern designed w/ 4 eq. ops. Over 10 years of goodwill. ID #4053. IRVINE - Great opportunity for GP or Specialist!! Leasehold & Equip Only! 5 eq. ops. located in busy large shopping center. ID #3401. ORANGE - Fee for service practice open 4 days/wk located in a single story med center w/ 4 eq. ops., on a 1,040 sq. ft. suite.ID #3531. ORANGE - GP located in downtown near Chapman University. Beautiful decor. Great views. Heavy traffic flow. ID # 4101. RANCHO STA MARGARITA - Leasehold & Equip Only! In modern single story med prof. bldg w/ mountain views. ID #4079. SANTA ANA - Absentee owner. Long established practice located a single standing bldg w/ ample parking. 4 eq ops. NET $82K. ID#4071 S. ORANGE COUNTY - Beautiful turnkey off located in a 5 story med/dent bldg. Absentee owner. Proj approx $208K for 2011.ID#4093. WESTMINSTER - Little Saigon area. Well established off. in a retail shopping center w/ 4 eq. ops. Seller works 4.5 days/wk. ID#4109.
RIVERSIDE / SAN BERNARDINO COUNTIES LAKE ELSINORE - Multi specialty office in a free standing strip mall. Absentee owner. Proj approx $1,084,277 for 2011. ID#4099. LA QUINTA - Leasehold & Equip Only! Office consist of 3 fully eq. ops., 1,000 sq. ft. suite located in a strip shopping center. ID#4063. MURRIETA - Equip, some charts & Condo for sale. Well design off w/ 4 ops, in 1,350 sqft single story condo. Newer equip. ID#3221. RANCHO MIRAGE - GP consist of 3 eq. ops., 1 chair in open bay. Great traffic flow and visibility. Proj approx $488K for 2011.ID# 4091 RANCHO MIRAGE (Perio) - Long established off in 1 story med/dent bldg w/ 4 eq. ops. Proj approx. $400K for 2011. ID#4089 UPLAND - Established in 2005. GP located in busy shopping center w/ excellent signage & visibility. 3 ops., 1 plmbd not eq. ID#4065.
SAN DIEGO COUNTY DEL MAR - Beautiful Décor office located in a one story medical dental building w/ ocean view. 3 fully eq. ops. Lots of traffic. ID #4083. SAN DIEGO - Over 27 yrs of gdwll. Fee for service. Located busy shopping cntr. Great visibility and signage and foot traffic. ID#4059. SAN DIEGO - Well established and still growing GP located on a major thorough fare in heart of S.D. 5 ops. NET $241K. ID#4107.
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Also serving you: Robert Palumbo, Executive V. P. /Partner, Alice C. King, V.P., John Knipf (Neff) President Greg Beamer, V.P., Tina Ochoa, V.P., & Maria Silva, V.P. Classifieds cda journal, vol 40, n 1 º
with existing computers & software. It is offices for rent or lease a ground-floor office, located across from How to Place a a beautiful city park, one mile from office for rent or lease — Highway 80, & one mile from downtown Classified Ad Professionally designed/built and newly Vacaville. An Endodontist, Oral Surgeon, equipped dental office for lease. Call & Orthodontist, & Prosthodontist are The Journal has changed its classified 408-839-4090. within walking distance. An experienced, advertising policy for CDA members to cross-trained RDA is also available. Call place free classified ads online and office for rent or lease — A 707-695-7229. publish in the Journal. Only CDA members turnkey dental office is available for a can place classified ads. Non-CDA members reasonable rent in the nicest neighbor- office for rent or lease — Start- can place display ads. hood of Vacaville, CA. Everything is ing in February 2012, prime office space present for a doctor (specialist or general- of 2,150 sq. ft. available in Salinas, CA. All classified ads must be submitted ist) who desires to start from scratch, or This office suite is in ideal location across through cda.org/classifieds. Fill out the relocate an existing practice. The office has the street from Salinas Valley Memorial blank fields provided, including whether 3 operatories, digital x-rays, & can be Hospital. This is a great opportunity to the ad is to appear online only or online easily converted to a paperless practice start a new practice or relocate an existing and in the Journal. Click “post” to submit your ad in its final form. The ad will be continues on 82 posted immediately on cda.org and will remain for 60 days.
Classified ads for publication in the Journal must be submitted by the fifth of every month, prior to the month of publication. Example: Jan. 5 at 5 p.m. is the deadline for the February issue of the Journal. If the fifth falls on a weekend or holiday, then the deadline will be 5 p.m. the following workday. After the deadline closes, classified ads for the Journal will not be accepted, altered or canceled. Deadlines are firm.
Classified advertisements available are: Equipment for Sale, Offices for Sale, Offices for Rent or Lease, Opportunities Available, Opportunities Wanted, and Practices for Sale.
For information on display advertising, please contact Corey Gerhard at 916- 554-5304 or [email protected].
CDA reserves the right to edit copy and does not assume liability for contents of classified advertising.
january 2012 81 jan. 12 classifieds
cda journal, vol 40, n 1 º
classifieds, continued from 81 practice. Office comprised of 5 plumbed days/Thursdays/Saturdays/Sundays opportunities available operatories, lab, reception, sterilization, 7 a.m. to 7 p.m. Three fully equipped conference or lunch room with wet bar, operatories: Digital X-ray, Dexis sensor, opportunity available — and upstairs are two private offices with hand pieces, physics forceps, basic set up Established and updated private dental storage rooms. No patient records or tray and disposables including anesthetic. practice seeking a part time to full time dental equipment included. All operato- Near 10, 605 and 60 Freeways. Wireless associate dentist. We are looking for a great ries have cabinets and sinks. Contact Dr. Internet, telephone and FAX. Parking lot. team player who enjoys treating both adults John Hirasuna at [email protected] Paid Utilities Rent per day is negotiable. and children. Our office has been successful or 831-484-9439. Upon request, photos Our RDA will assist on hourly base (paid in providing high quality general, implant & will be emailed. in addition to rent). Hitomi Dentistry, cosmetic dentistry and wish to continue 11525 Lambert Ave., El Monte, CA 91732. our success with the addition of one office for rent or lease — Hitomi Call 626-443-5900 or email office@ associate who could be either new or Dentistry (General Practice) is seeking for hitomidentistry.com. For pictures visit experienced and has the desire to provide a a long term contract opportunity to rent www.facebook.com/HitomiDentistry or wide range of treatment. We are located in our office space to a Specialist on Mon- www.hitomidentistry.com. a wonderful town that is centrally located and minutes away from both Fresno and Visalia. Resumes can be emailed to [email protected] or faxed to 559-897-2622. SINCE 1987 opportunity available — Nor Cal GOLDEN STATE PRACTICE SALES sm United Specializing In Northern & Central California Practice Sales & Consulting Indian Health Services (UIHS), a nonprofit community clinic providing health care to James M. Rodriguez, MA, DDS 44 Holiday Drive, P.O. Box 1057, Alamo, CA 94507 American Indian people & their families, is DRE Licensed Broker # 957227 seeking a FT Dentist to provide outpatient v MARIN COUNTY - Coll. $332K, 3 ops, between Sausalito and San Rafael. care. Located in beautiful northern SOLD California, UIHS offers an opportunity for v PERIODONTAL - S.F. EAST BAY - Established 30 plus years. Well personal and professional growth. This known and respected in dental community. Seller will stay on contractually position will work closely with a team of for introduction to established referral base. other dentists & hygienists in providing v CENTRAL CONTRA COSTA - DANVILLE - Established family culturally sensitive, high quality & practice priv/ins UCR, $1.2M collections, 4 operatories. SOLD comprehensive health care services to the v SOUTH LAKE TAHOE - For Lease. 5 ops. Not equipped. No upgrades or Indian Community. Computer skills & additions needed. Call for details. ability to work in fast paced environment v DUNSMUIR - SHASTA - Dental office bldg for sale. Call for referral. required. Competitive wages & benefits. v CENTRAL VALLEY - 3 ops., collections $725K. PENDING Salary $109,907/yr and up DOE Closes: Open until filled. Contact trudy.adams@ Practice Sales - Presale Complimentary Consultations and Valuation Estimates crihb.net or call 707-825-4036. Practice Appraisals and Forensic Services - Independent Practitioner Programs Each Transaction Handled Personaly From Start To Finish opportunity available — Looking Buyer Consultant Service Available for RDA with minimum 2 years exp in STRICT CONFIDENTIALITY OBSERVED Pedo. Position is for two Fridays out of the 925-743-9682 month. Bilingual is a strong plus! Please Integrity-Experience-Knowledge-Reputation reply by email to nuevodentalclinic@gmail. e-mail: [email protected] com or fax 951-928-2842. continues on 86 82 NorCal_GoldenState_Template.inddjanuary 2012 1 8/15/11 3:32 PM
PROFESSIONAL PRACTICE TRANSITIONS PROFESSIONAL PRACTICE TRANSITIONS
“DENTAL PRACTICE BROKERAGE” Making your transition a reality. For more information regarding the listings below: More information is available on our website regarding practices VISIT OUR WEBSITE AT: Practice Sales • Mergers WWW.PPTSALES.COM Partnerships • Appraisals Dr. Dennis Hoover listed in other states, articles, Western Regional Manager Dr. Thomas Wagner Jim Engel Thinh Tran Mario Molina & Corporate Broker Transitions Consultant Transitions Consultant Transitions Consultant Transitions Consultant CA R.E. Lic. #01233804 upcoming seminars and more. (Practice Opportunities) Patient Record Sales NV R.E. Lic. #0053890 • NV B.O. Lic. #0000301 CA R.E. Lic. #01418359 CA R.E. Lic. #01898522 CA R.E. Lic. #01863784 CA R.E. Lic. #01423762 • EL DORADO HILLS:• EL For DORADO Sale-General HILLS: Dentistry For Sale- Practice.General •Dentistry GRASS Practice. VALLEY: • For GRASS Sale -General VALLEY: Dentistry For Sale Practice.-General Dentistryof an attractive Practice. Medical of anDental attractive office Medical building. Dental Gross office receipts building. Gross receipts • NORTHERN FRESNO:• NORTHERN For Sale-General FRESNO: Dentistry For Sale Practice.-General • Dentistry ROSEVILLE: Practice. For • Sale ROSEVILLE:-General Dentistry For Sale Practice.-General Great Dentistry • SANTA Practice. CLARA: Great •For SANTA Sale - BUILDINGCLARA: For ONLY: Sale -This BUILDING building ONLY: This building 2009 GR $790,758, adjusted2009 GR net $790,758, income ofadjusted $312K. net Intra-oral income of $312K.Gross ReceiptsIntra-oral $491KGross with Receipts an adjusted $491K net with income an adjusted of were net $676,000income of with werea $174K $676,000 adjusted with net a income.$174K adjustedDentist isnet income. Dentist is This is a perfect starterThis or satellite is a perfect practice. starter Excellent or satellite location practice. in ExcellentLocation. location 2009 in GR Location.$900K with 2009 adjusted GR $900K net income with adjustedof is netlocated income just ofwest ofis Westfieldlocated just Mall west and of SantanaWestfield Row. Mall The and Santana Row. The camera, pano, Softdentcamera, software, pano, 4-equipped Softdent SOLD software,ops. 6-hygiene 4-equipped $130K. ops. 6-hygiene Overhead 73%.$130K. Office Overhead leased 1,555 73%. sq Office ft. 4 equipped leased 1,555 retiring sq ft. 4 afterequipped 39 years. retiring 4 days afterof hygiene. 39 years. Additional 4 days of operatories hygiene. Additional operatories North Fresno. GrossNorth Receipts Fresno. in Gross2010 Receiptswere $173K. in 2010 $300K. were 1,975$173K. sq. ft. with$300K. 4 ops, 1,975 8 days sq. ft.hygiene/wk. with 4 ops, Digital, 8 days hygiene/wk.building hasDigital, two units.building One side has istwo designed units. Oneand sideplumbed is designed for and plumbed for days. Practice has beendays. in its Practice present has location been infor its past present 18 years. location foroperatories past 18 years.5 available. operatories Laser, Intra-Oral 5 available. Camera, Laser, Cerac, Intra-Oral & Camera,could be Cerac, added &to existingcould space. be added Great to location.#14376.existing space. Great location.#14376. Approximately 450 Approximatelyactive patients. 4503 operatories.active patients. Dentrix 3 operatories.Intra-Oral Dentrix Camera, Dentrix,Intra-OralSOLD Trojan, Camera, fiber Dentrix, optics, Trojan,P & C fiber dentistry optics, andP & the C other dentistry was a law and office. the other There was is a 3,776 law office. sq. ft. Thereof is 3,776 sq. ft. of Owner retiring. Owner retiring. Eaglesoft software. OwnerEaglesoft would software. like to retire.Owner #37108. would like to retire. #37108. software. Leased officesoftware. 1,200 sq. Leased ft. Owner office has 1,200 been sq. accepted ft. Owner to haschairs been accepted- all less tothan 5chairs years old.- all Ownerless than is 5retiring. years old. #14327 Owner is retiring.office space. #14327 The dentaloffice office space. is approximately The dental office 1,800 is sq. approximately ft. with 1,800 sq. ft. with • LEMOORE/HANFORD• LEMOORE/HANFORD AREA: For Sale-General AREA: Dentistry For Sale -General Dentistry an Endodontic Residencyan Endodontic after starting Residency practice after1 1/2 starting years ago. practice 1 1/2 years ago. 6 operatories. The 6building operatories. has beenThe buildingrecently hasre-roofed. been recently re-roofed. • EL DORADO HILLS:• EL DORADOFor Sale-General HILLS: dentistry For Sale- practice.General dentistry practice. • GREATER CHICO:• GREATER For Sale-General CHICO: Dentistry For Sale- Practice.General DentistryPractice Practice.& Building. PracticeOwner has& Building.worked in Owner this location has worked since in this location since • SACRAMENTO: • For SACRAMENTO: Sale-General DentistryFor Sale-General Practice. DentistryExcellent Practice. opportunity Excellent for a startup opportunity practice orfor for a startupthe dentist practice that or for the dentist that Gross Receipts of $834KGross with Receipts adj net of of $834K $389K, with 53% adj overhead. net of $389K, 53% overhead. Gross receipts in 2010Gross were receipts $584K, in with 2010 an were adjusted $584K, net with1971. an adjusted Gross Receipts net 1971.were $378KGross Receiptswith $139K were adj. $378K net income.with $139K adj. net income. • NORTHERN CALIFORNIA:• NORTHERN For CALIFORNIA:Sale-Endodontic ForPractice. Sale-Endodontic Practice. Gross Receipts $546K with adjusted net income of $159K. needs more space. Financing available through various dental Office has five equippedOffice operatorieshas five equipped in 1485 operatoriessq.ft. Pano, in 1485 sq.ft. Pano, Gross Receipts $546K with adjusted net income of $159K. needs more space. Financing available through various dental SOLD income of $152K. incomeApprox of1,100 $152K. active Approx patients. 1,100 4 activeThere patients. are 3 equipped4 There operatories are 3 equipped and 3 daysoperatories of hygiene. and 3 days of hygiene. This Endodontic practiceThis isEndodontic located in practicean upscale is locatedprofessional in an upscale professional Intra-oral Camera, Dentrix,Intra-oral 5 days Camera, of hygiene. Dentrix, Owner 5 days retiring. of hygiene. Owner retiring. Office is 2,400 sq ft Officewith 7 isoperatories. 2,400 sq ft Practice with 7 operatories.has been Practicelenders. has#14368 been lenders. #14368 operatories, Pano, Intra-Oraloperatories, Camera. Pano, Easy Intra-Oral dental Camera.software. Easy Purchase dental software. of the buildingPurchase is optionalof the buildingto the Buyer.is optional 100% to the Buyer. 100% office complex. The ownersoffice complex.condominium The ownersoccupies condominium 1,770 sq ft, occupiesoperating 1,770 in sqthe ft, same operating location infor the the same past location50 years. for Pano, the past 50 years. Pano, • FOLSOM: For Sale• -General FOLSOM: Dentistry For Sale Practice.-General Gross Dentistry Receipts Practice. Leased Gross office Receipts 1,200 sq.Leased ft. Owner office is 1,200retiring. sq. #14359.ft. Owner is retiring.financing #14359. is availablefinancing for both buildingis available and for practice. both building Excellent and practice. Excellent There are 4 equippedThere treatment are 4 rooms equipped with treatment an additional rooms 5th with anSoftdent additional software. 5th OwnerSoftdent to retire. software. #14374 Owner to retire. #14374• SANTA CRUZ: For• SANTA Sale-General CRUZ: Dentistry For Sale practice.-General GrossDentistry practice. Gross in 2010 were $703K inwith 2010 an adjustedwere $703K net incomewith an ofadjusted $300K. net 5 income of $300K. 5 opportunity for new gradopportunity or satellite for practice. new grad #14375. or satellite practice. #14375. room available. Grossroom Receipts available. were Gross $638K Receipts with $239Kwere $638K with $239K Receipts $300K with Receiptsa 57% overhead. $300K with Office a 57% is 1,140 overhead. sq. ft. Office 3 is 1,140 sq. ft. 3 days of hygiene and approx1500days of hygiene active and patients. approx1500 Leased active Office patients. • GREATER Leased Office SAN • GREATER JOSE AREA: SAN For JOSE Sale- AREA:General For Sale-General adjusted net income. Owneradjusted will net stay income. for transition Owner will to introduce stay for transition • SACRAMENTO/ROSEVILLE: to introduce • SACRAMENTO/ROSEVILLE: For Sale-One of many For Sale-equippedOne of operatories. many equippedIntra-Oral operatories. Camera, Pano, Intra-Oral Digital Camera, X-Rays, Pano, Digital X-Rays, is 2,000 sq ft with 4is equipped 2,000 sq operatories-5 ft with 4 equipped SOLDpossible. operatories-5 Patient Endodonticpossible. Patient Practice. 2009Endodontic Collections Practice. were 2009 $1,187MIL Collections with were • LINDSAY:$1,187MIL withFor Sale• LINDSAY:-General Dentistry For Sale Practice-General & Dentistrybuilding. Practice & building. buyer. Owner is retiring.buyer. #14251 Owner is retiring. #14251 partners is retiring in thispartners highly is successfulretiring in thisGeneral highly Dentistry successful Generaland Dentrix Dentistry software. and Practice SOLDDentrix has software. been in Practiceits present has location been in its present location Base software. OwnerBase to retire. software. Owner to retire. an adjusted net incomean adjustedof $696K. net There income are of4 ops$696K. in this There areGross 4 opsReceipts in this $330K Gross with Receipts adjusted $330K net income with adjustedof $219K. net income of $219K. Group Practice. Intra-OralGroup Practice.Camera, DigitalIntra-Oral Pano-Dexis, Camera, Digitalsince Pano-Dexis, 1980. Owner retiring.since 1980.#14358. Owner retiring. #14358. nicely decoreated 1,400nicely sq ftdecoreated office space. 1,400 4 sqmicroscopes. ft office space. Owner 4 microscopes. has operated inOwner present has location operated for in27 present years. Officelocation space for 27 years. Office space • NORTHERN CALIFORNIA:• NORTHERN For CALIFORNIA: Sale-Pediatric practice.For Sale -Pediatricelectronic practice. charts, ownerelectronic Financing. charts, Callowner for Financing. further Call for further • FOLSOM: For Sale• -General FOLSOM: Dentistry For Sale Practice.-General Gross Dentistry Receipts Practice. Gross Receipts Owner has been in sameOwner location has beenfor 26 in years same with locationSOLD long-term for 26 years1,489 with sq. long-term ft., 3 operatories 1,489 sq.available ft., 3 operatories(2 equipped), available Intra-Oral (2 equipped), Intra-Oral Owner has operated inOwner same locationhas operated for 32 in years. same Approxlocation 1,760 for 32 years.information. Approx 1,760 #14334 information. #14334 • SANTA CRUZ: •For SANTA Sale-General CRUZ: Dentistry For Sale practice.-General ThisDentistry practice. This in excess of 1.5M thein past excess three of years. 1.5M Adjusted the past threeNet of years. $550K. Adjusted Net of $550K. employees. Owner is retiringemployees. but willOwner continue is retiring to work but 1will ½ tocontinue Camera, to work Soft-Dent 1 ½ to software.Camera, 3-hygieneSoft-Dent dayssoftware. a week. 3-hygiene Owner days a week. Owner active pts, 1,160 sq activeft, panoramic pts, 1,160 X-Ray, sq ft, Dexis panoramic Digital X-Ray, and Dexis Digital and excellent practice is centrallyexcellent located practice in isa professionalcentrally located complex. in a professional complex. 2,700 sq. ft. office with2,700 7sq. ops, ft. Digital,office withDentrix, 7 ops, Intra-Oral Digital, Dentrix,2 years Intra-Oralthrough the transition2 years throughwith the the buyer. transition with the buyer. retiring. #14363. retiring. #14363. Dentrix software in thisDentrix 5–chair software office. in 2009this 5–chairGross Receipts office. 2009 Gross Receipts • SAN BERNARDINO: For Sale-General Dentistry Practice. Office is approx. 1,885 sq. ft., 4 operatories with room for one Camera, Laser, 5+yearCamera, old equipment, Laser, 5+year 8 days old hygiene.SOLD equipment, Beautiful 8 days hygiene. Beautiful SOLD • SAN BERNARDINO: For Sale-General Dentistry Practice. Office is approx. 1,885 sq. ft., 4 operatories with room for one $713K with 48% overhead.$713K Ownerwith 48% retiring. overhead. Call for Owner Details. retiring. CallGR for $972K. Details. Practice hasGR been$972K. in itsPractice present has location been in for its the present additional. location for There the are approx.additional. 2000 There active are patients approx. with 2000 6 activedays of patients with 6 days of office, great location. office,Owner great retiring. location. #14336 Owner retiring. #14336• HAWAII (MAUI):• HAWAIIFor Sale- General (MAUI): dentistry For Sale- practice.General •dentistry LIVERMORE: practice. For• LIVERMORE:Sale-General Dentistry For Sale Practice.-General 2009Dentistry Practice. 2009 past 35 years. Leased 4,500past 35 sq years. ft of officeLeased space- 4,500 12 sq equipped ft of office space-hygiene 12 equippedper week. Practicehygiene Pano, per week.Intra-Oral Practice Camera Pano, and Intra-Oral Easy Camera and Easy Gross Receipts of Gross$636K. Receipts Office ofhas $636K.four equippedOffice hasCollections four equipped were $688KCollections with an adjustedwere $688K net income with an of adjusted $287K. net income of $287K. For Sale-General Dentistry Practice. • OCEANSIDE: For• Sale OCEANSIDE:-Modern looking For Sale office.-Modern 4 op, lookingoffice office.operatories. 4 op, office Dentrix operatories.software, Pano Dentrix and software,Cerac. Accepts Pano and DentalCerac. software. Accepts OwnerDental is retiring. software. Reasonable Owner is leaseretiring. available. Reasonable lease available. • FOUNTAIN VALLEY:• FOUNTAIN For Sale-General VALLEY: Dentistry Practice. operatories in 1198 sq.ft.operatories Pano, inLaser, 1198 I.O.sq.ft. Camera, Pano, FiberLaser, I.O.There Camera, are 4 Fiberops in thisThere nicely are updated 4 ops in1,082 this nicelysq. ft. officeupdated space. 1,082 sq. ft. office space. Gross Receipts $284,000 with only a 47% overhead. Practice space and equipmentspace only. and Belmont equipment chairs. only. Gendex Belmont x-ray chairs. Gendex x-ray Gross Receipts $284,000 with only a 47% overhead. Practice Optics, 2 ½ days of hygiene.Optics, Owner2 ½ days retiring: of hygiene. Don’t Owner miss this retiring: Dentrix Don’t misssoftware, this 6-days/wkDentrix hygiene.software, Owner 6-days/wk hasSOLD beenhygiene. in same Owner has been in same HMO. Multi-specialtyHMO. practice. Multi-specialty Owner to relocate. practice. #14377 Owner to relocate.#14361 #14377 #14361 has been in its present location for the past 37 years. There are system, intraoral camera, approx 1200 sq ft. Low overhead-Rent has been in its present location for the past 37 years. There are opportunity to live andopportunity work in paradise. to live and#20101 work in paradise. #20101location for 36 yearslocation with long-termfor 36 years employees. with long-term Owner isemployees. Owner is system, intraoral camera, approx 1200 sq ft. Low overhead-Rent two equipped operatories in this 5 op office. E2 2000 software. two equipped operatories in this 5 op office. E2 2000 software. retiring. #14326 retiring. #14326 is $1,900/month, andis it's $1,900/month, a 5 year lease. and Staff it's ais 5available year lease. for Staff• SAN is available DIEGO: for For • Sale SAN-General DIEGO: Dentistry For Sale practice.-General Gross Dentistry • TORRANCE: practice. Gross For • TORRANCE:Sale-General DentistryFor Sale -Generalpractice. DentistryThis practice. This Doctor is retiring. SOLD Doctor is retiring. • HAYWARD: For • Sale- HAYWARD:General Dentistry For Sale- Practice.General ThisDentistry Practice. This rehire-front desk $15/hr,rehire-front assistant 13/hr.desk $15/hr, Update assistant all the computer 13/hr. Update Receipts all the computer $414K. PracticeReceipts has $414K.been operated Practice by has the been same operated excellent by the practice same is centrallyexcellent located practice in isa professionalcentrally located complex. in a professional complex. practice consists of 1,600practice sq ft consists with 4 treatmentof 1,600 sqrooms ft with in an4 treatment • LOS roomsANGELES: in an •For LOS Sale ANGELES:-General Dentistry For Sale Practice.1,200-General Dentistry sq Practice.1,200 sq systems after purchasingsystems the afteroffice purchasing in 07. Computers the office andin 07. ownerComputers for the and past 6 years.owner Leasedfor the 950past sq.6 years. ft. office Leased with 950 3 sq.Office ft. office is approx. with 3 1,885Office sq. ft., is approx.4 operatories 1,885 withsq. ft., room 4 operatories for one with room for one For Sale-General Dentistry IV Sedation Practice. • FRESNO: For Sale• -General FRESNO: Dentistry IV Sedation Practice. excellent location. 2010excellent Gross location.was $501,000 2010 withGross a was$228K $501,000 ft 4ops, with a29 $228K yrs in presentft 4ops, location. 29 yrs Gross in present Receipts location. $274K Gross with Receipts $274K with monitors in every room.monitors #14346 in every room. #14346 equipped operatories.equipped Dentix software,operatories. Intra-Oral Dentix camera,software, Intra-Oraladditional. camera, There are approx.additional. 2000 There active are patients approx. with 2000 6 activedays of patients with 6 days of (MERGER OPPORTUNITY) Owner would like to merge his SOLD (MERGER OPPORTUNITY) Owner would like to merge his adjusted net income. Dentaladjusted Vision net income. software, Dental AverageSOLD Vision age software, of adjusted Average net age income of ofadjusted $89K. Ownernet income to retire. of $89K. #14348 Owner to retire. #14348 Panoramic X-Ray. OwnerPanoramic to relocate. X-Ray. #14356. Owner to relocate. #14356.hygiene per week. Practicehygiene Pano, per week.Intra-Oral Practice Camera Pano, and Intra-Oral Easy Camera and Easy practice into another high quality general dentistry or IV practice into another high quality general dentistry or IV equipment is 8 yrs. Approximatelyequipment is 81,200 yrs. Approximatelyactive patients. 1,200 active patients. • PLEASANTON: For• PLEASANTON: Sale-General Dentistry For Sale Practice.-General Owner Dentistry Practice. Owner Dental software. OwnerDental is retiring. software. Reasonable Owner is leaseretiring. available. Reasonable lease available. sedation practice. Thesedation merger practice. would beThe into merger Buyers would office. be into Buyers office. • MARIN COUNTY:• MARINFor Sale -GeneralCOUNTY: Dentistry For Sale Practice.-General This Dentistry Practice. This has other practice in Bayhas Areaother only practice in Pleasanton in Bay Area 1 day/wk. only in Pleasanton300 • SAN 1 day/wk. DIEGO: 300 For • Sale- SANGeneral DIEGO: Dentistry For Sale- Practice.General 6 Dentistryops, #14320 Practice. 6 ops, #14320 Seller would like to continue to work as either a partner or Seller would like to continue to work as either a partner or • IRVINE & COSTA• IRVINE MESA: &For COSTA Sale-General MESA: Dentistry For Sale- Generalis a small Dentistry 650 sq.ft. isoffice a small with 650 three sq.ft. treatment office withrooms. three The treatment rooms. The active patients. Excellentactive location-beautiful patients. Excellent 1600 location-beautiful sq.ft. 5-op Intra-Oral1600 sq.ft. camera, 5-op EagleIntra-Oral Soft Software. camera, EagleOffice Soft square Software. feet Office square feet associate after the merger. 2010 collections were $993K with a associate after the merger. 2010 collections were $993K with a practice combined. Grosspractice receipts combined. combined Gross $781K receipts with combined practice $781K has witha very lowpractice overhead has a ofvery only low 48%. overhead 2010 ofgross only 48%. 2010 gross office. Equipment likeoffice. new, Equipment intra-oral likecamera, new, pano, intra-oral Easy camera,2,300 pano, with 3Easy years remaining2,300 with on 3lease. years 2009 remaining Gross onReceipts lease. 2009• TORRANCE: Gross Receipts For • Sal TORRANCE:e - General DentistryFor Sale -Practice. General GrossDentistry Practice. Gross $422K adjusted net income. There are 7 days of hygiene. $422K adjusted net income. There are 7 days of hygiene. adjusted net of $396K.adjusted Both officenet of spaces$396K. are Both leased office with spaces receipts are leased were with $179,000 receipts with were$90,000 $179,000 adjusted with net. $90,000 Practice adjusted net. Practice Dental software. MustDental See. #14364. software. Must See. #14364. $1,448,520, with an adjusted$1,448,520,SOLD net incomewith an ofadjusted $545K. net Doctor income ofReceipts $545K. $413K Doctor with Receipts an adjusted $413K net with income an adjustedof $203K. net 50% income of $203K. 50% #14250. #14250. 4-5 ops in each. Both 4-5are 1,600ops in sq. each. ft. IrvineBoth are is equipped1,600 sq. withft. Irvine includes is equipped Panoramic with X-rayincludes and PanoramicEasy Dental X-ray Software. and Easy Refers Dental out Software. Refers out would like to phase outwould then likeretire. to #14331phase out then retire. #14331 overhead. Practice hasoverhead. been in its Practice present has location been infor its the present past 25 location for the past 25 Intra-Oral Camera, PanoIntra-Oral & Dentrix. Camera, Costa Pano Mesa & isDentrix. equipped Costa MesaO.S., Perio.,is equipped & Endo. PracticeO.S., Perio., has been& Endo. in its Practice present has location been infor its present location for • PLUMAS COUNTY:• PLUMAS For Sale-3 COUNTY: equipped ops. For SpaceSale-3 available equipped ops. Space available years. The office has beenyears. tastefully The office remodeled. has been tastefully Office is remodeled.800+ Office is 800+ FACILITY SALE-General Dentistry Office Space • GLENDALE: FACILITY• GLENDALE: SALE-General Dentistry Office Space with Laser, Intra-Oralwith Camera, Laser, Pano Intra-Oral and Dentrix. Camera, #14355. Pano and Dentrix.30 years. #14355. This is an ideal30 years. practice This for is thean idealnew gradpractice or satellite for the new grad or satellite for 4th op. 1,245 sf foroffice 4th inop. good 1,245 location. sf office Gross in good Receipts location. • SANTA Gross ReceiptsBARBARA: • SANTA For Sale BARBARA:-General Dentistry For Sale Practice.-General Dentistrysq. ft. with Practice. 3 equipped sq. operatories. ft. with 3 equipped 4 -hygiene operatories. days per week.4 -hygiene days per week. & Leasehold Improvements Sale- Office located in a medical & Leasehold Improvements Sale- Office located in a medical practice for the establishedpractice dentist. for the Owner established is retiring. dentist. #14370 Owner is retiring. #14370 $475K. Practice in present$475K. location Practice over in present 50 years. location Owner over is 50 Thisyears. excellent Owner practice’sis This 2009 excellent gross practice’s Receipts 2009$891K gross with Receipts Doctor $891K is to retire.with #14369Doctor is to retire. #14369 plaza, 1760 sq. ft. 7 operatories, computerized equipment plaza, 1760 sq. ft. 7 operatories, computerized equipment • LAGUNA NIGUEL:• LAGUNA For Sale- General NIGUEL: Dentistry For Sale- Practice.General Dentistry Practice. retiring. #14318 retiring. #14318 steady increase everysteady year. Practiceincrease hasevery 6 daysyear. of Practice hygiene. has 6 days of hygiene. approximately 5 yearsapproximately old. Two 5-year 5 yearsoptions old. available. Two 5-year #14373 options available. #14373 2010 gross receipts2010 were gross $503k. receipts 4 operatories, were $503k. Pan, 4 • operatories, MODESTO-TRACY-STOCKTON Pan, • MODESTO-TRACY-STOCKTON AREA: For Sale-Pediatric AREA: For Sale-Pediatric 1,690 sq. ft., 5 ops, Laser,1,690 Intra-Oral sq. ft., 5 ops,Camera, Laser, Schick Intra-Oral Digital Camera, • TRACY: Schick ForDigital Sale-Equipment, • TRACY: furnishings,For Sale-Equipment, and leaseholds furnishings, only. and leaseholds only. computerized with EZcomputerized dental software. with 1,500 EZ dental sq. ft. software.lease. 10 1,500Practice. sq. ft. lease. $677,000 10 inPractice. collections $677,000 in 2010 in with collections a $357,000 in 2010 net with a $357,000 net • RENO: For Sale•-General RENO: DentistryFor Sale -GeneralPractice andDentistry Dental Practice X-Ray, and Datacon Dental software. X-Ray,SOLD Doctor Datacon has software.been practice Doctor in samehas been Inpractice the Central in same Valley. In Fullythe Central equipped Valley. including Fully 4equipped Belmont including 4 Belmont • GRASS VALLEY:• For GRASS Sale-General VALLEY: Dentistry For Sale- Practice.General GR Dentistry of Practice. GR of years in present location.years Owner in present retiring. location. #14352 Owner retiring. #14352income. This 3-chair officeincome. is Thislocated 3-chair in approximately office is located 1,250 in sqapproximately 1,250 sq Building: 2009 Gross Building:Receipts $517K2009 Gross with adjustedReceipts net$517K income with adjustedlocation net for income the past locationeleven years for theof hispast 31 eleven years years in Santa of his 31Accutrac years in chairs, Santa 2 MidmarkAccutrac chairs, chairs, 6 DCI2 Midmark rear delivery chairs, units, 6 DCI 3 rear delivery units, 3 $307,590 (3 days/wk)$307,590 with adjusted (3 days/wk) net income with adjustedof $105K. net 3 income of $105K. 3 ft & has recently beenft remodeled. & has recently Patient been Base remodeled. software. Patient Office Base software. Office of $165K. 4 ½ hygieneof days/week. $165K. 4 ½ 1, hygiene 800 sq. ft.days/week. with 6 equipped 1, 800 sq. ft.Barbara. with 6 equipped Doctor is retiring.Barbara. #14333 Doctor is retiring. #14333 Gendex x-ray units, 1Gendex Soridexdigital x-ray units, x-ray 1 processor,Soridexdigital 1 Statim x-ray processor, 1 Statim Ops. refers out most/allOps. Ortho. refers Perio, out most/all Endo, Surgery. Ortho. Perio,Intra-Oral Endo, Surgery. Intra-Oral • For LAKE Sale- COUNTY:General Dentistry For Sale- Practice.General Dentistry Practice. SOLD • LAKE COUNTY: equipped for NO2 &equipped IV sedation. for NO2Practice & IVhas sedation. operated Practice in its has operated in its ops. (7 Avail). Dentrixops. software,SOLD (7 Avail). Pano. Dentrix Practice software, has been Pano. in itsPractice has been in its 5000, 1 Harvey autoclave.5000, 12,800 Harvey Sq autoclave.ft, 6 Ops. 2,800 New Sqlease ft, 6 Ops. New lease Camera, Diagnodent,Camera, EZ Dental Diagnodent, Software. EZ Good Dental Location. Software. GrossGood ReceiptsLocation. 904K Grosswith adjusted Receipts net 904K $302K. with Practiceadjusted has net $302K. Practice has present location for 20present years. location for 20 years. present location for 40present years. locationOwner retiring for 40 years. Owner retiring• SAN LUIS OBISPO:• SAN For LUIS Sale OBISPO:- Two Doctor For SaleGeneral - Two availableDoctor Generalfrom landlord. available #14335. from landlord. #14335. Owner retiring. #14337.Owner retiring. #14337. been in same locationbeen for past in same 23 yrs, location and 25 for yrs past in previous23 yrs, and 25 yrs in previous Dentistry Practice. GrossDentistry receipts Practice. $1,537,142 Gross for receipts 2010 with$1,537,142 for 2010 with location. 2,600 sq ftlocation. with 8 2,600equipped sq fttreatment with 8 rooms.equipped • treatment NEWPORT rooms. BEACH: • NEWPORT For Sale -General BEACH: Dentistry For Sale Practice.-General Dentistry Practice. For Sale-General Dentistry Practice. GR • ROCKLIN: For • Sale ROCKLIN:-General DentistryFor Sale -GeneralPractice. DentistryGross anPractice. adjusted Grossnet income an of adjusted $691K. netThe income office hasof $691K. 2,331 sq. The ft. office • VISALIA: has 2,331 sq.For ft. Sale- • General VISALIA: Dentistry For Sale- Practice. General Gross Dentistry Receipts Practice. Gross Receipts • GRASS VALLEY:• For GRASS Sale- GeneralVALLEY: Dentistry Practice. GR Intral-Oral Camera, Pano,Intral-Oral and Data Camera, Con software. Pano, and Owner Data Conto software.Practice Owner has operated to Practiceat its present has operated location atsince its present 1986. Located location since 1986. Located 545K 3 days/wk (4 avail). 3 hygiene days/week. 5 Ops (6 Avail) Receipts $593K in 2010Receipts with $593K $240K in adjusted 2010 with net $240Kincome. adjusted with net8 equippedincome. operatories.with 8 equipped Pano, E4D,operatories. and Dentrix Pano, E4D,$616K and with Dentrix an adjusted $616K net income with an of adjusted $ 321K. net Office income is 1,380 of $ 321K.sq Office is 1,380 sq 545K 3 days/wk (4 avail). 3 hygiene days/week. 5 Ops (6 Avail) retire. #14338 retire. #14338 in a highly affluent inNewport a highly Beach affluent community. Newport ThreeBeach (3)community. Three (3) 1,950 sq ft. Refers out most/all Ortho, Perio, Endo, Surgery. Office is 1,630 sq. ft.,Office with is4 operatories1,630 sq. ft., equipped with 4 operatorieswith fiber equippedsoftware. with Practice fiber startedsoftware. in 1990 Practice and has started been inin 1990its present and has beenft with in its 3 present equipped ftoperatories, with 3 equipped Intra-Oral operatories, Camera, DigitalIntra-Oral Camera, Digital 1,950 sq ft. Refers out most/all Ortho, Perio, Endo, Surgery. hygiene days per week.hygiene Leased days office per space week. with Leased 4 ops. office in 1,450 space with 4 ops. in 1,450 Office has Laser, Intraoral Camera, Pano, &• Dentrix LANCASTER: Software. For • Sale- LANCASTER:General Dentistry For Sale- Practice.General This Dentistry 4 Practice. This 4 SOLD optics. Owner has beenoptics. inSOLD present Owner location has been for in the present past 13 location years. for locationthe past 13since years. 1998. locationApprox. since3000 1998.active Approx.patients. 3000 Great active X-Rays, patients. Mogo Great software, X-Rays, equipmentSOLD Mogo software,& leaseholds equipment look new. & leaseholds5 look new. 5 Office has Laser, Intraoral Camera, Pano, & Dentrix Software. sq. ft. Pano & Practicesq. Works ft. Pano software. & Practice #14354. Works software. #14354. Owner retiring. #14372.Owner retiring. #14372. operatory office is locatedoperatory in 2,360 office Sq isFt located on the secondin 2,360 floor Sq Ft on the second floor 3 1/2 days hygiene. Intra-Oral3 1/2 days Camera, hygiene. Dentrix Intra-Oral software. Camera, Owner Dentrix location software. with Owner nice views.location #14353. with nice views. #14353. years in present location.years Owner in present to relocate. location. #14347 Owner to relocate. #14347 to retire. to retire. CALIFORNIA / NEVADA REGIONAL OFFICE CALIFORNIA / NEVADA REGIONAL OFFICE HENRY SCHEIN PPT INC. Henry Schein PPT Inc., Real Estate Agents California Regional Coporate Office and Transitions Consultants DR. DENNIS HOOVER, Broker Office:(800) 519-3458 Office (209) 545-2491 Dr. Tom Wagner (916) 812-3255 N. Calif. Mario Molina (323) 974-4592 S. Calif. Fax (209) 545-0824 Email: [email protected] Jim Engel (925) 330-2207 S.F./Bay Area Thinh Tran (949) 533-8308 S. Calif. PROFESSIONAL PRACTICE TRANSITIONS 5831 Stoddard Road, Ste. 804 Modesto, CA 95356 PROFESSIONAL PRACTICE TRANSITIONS PROFESSIONAL PRACTICE TRANSITIONS
“DENTAL PRACTICE BROKERAGE” Making your transition a reality. For more information regarding the listings below: More information is available on our website regarding practices VISIT OUR WEBSITE AT: Practice Sales • Mergers WWW.PPTSALES.COM Partnerships • Appraisals Dr. Dennis Hoover listed in other states, articles, Western Regional Manager Dr. Thomas Wagner Jim Engel Thinh Tran Mario Molina & Corporate Broker Transitions Consultant Transitions Consultant Transitions Consultant Transitions Consultant CA R.E. Lic. #01233804 upcoming seminars and more. (Practice Opportunities) Patient Record Sales NV R.E. Lic. #0053890 • NV B.O. Lic. #0000301 CA R.E. Lic. #01418359 CA R.E. Lic. #01898522 CA R.E. Lic. #01863784 CA R.E. Lic. #01423762 • EL DORADO HILLS:• EL For DORADO Sale-General HILLS: Dentistry For Sale- Practice.General •Dentistry GRASS Practice. VALLEY: • For GRASS Sale -General VALLEY: Dentistry For Sale Practice.-General Dentistryof an attractive Practice. Medical of anDental attractive office Medical building. Dental Gross office receipts building. Gross receipts • NORTHERN FRESNO:• NORTHERN For Sale-General FRESNO: Dentistry For Sale Practice.-General • Dentistry ROSEVILLE: Practice. For • Sale ROSEVILLE:-General Dentistry For Sale Practice.-General Great Dentistry • SANTA Practice. CLARA: Great •For SANTA Sale - BUILDINGCLARA: For ONLY: Sale -This BUILDING building ONLY: This building 2009 GR $790,758, adjusted2009 GR net $790,758, income ofadjusted $312K. net Intra-oral income of $312K.Gross ReceiptsIntra-oral $491KGross with Receipts an adjusted $491K net with income an adjusted of were net $676,000income of with werea $174K $676,000 adjusted with net a income.$174K adjustedDentist isnet income. Dentist is This is a perfect starterThis or satellite is a perfect practice. starter Excellent or satellite location practice. in ExcellentLocation. location 2009 in GR Location.$900K with 2009 adjusted GR $900K net income with adjustedof is netlocated income just ofwest ofis Westfieldlocated just Mall west and of SantanaWestfield Row. Mall The and Santana Row. The camera, pano, Softdentcamera, software, pano, 4-equipped Softdent SOLD software,ops. 6-hygiene 4-equipped $130K. ops. 6-hygiene Overhead 73%.$130K. Office Overhead leased 1,555 73%. sq Office ft. 4 equipped leased 1,555 retiring sq ft. 4 afterequipped 39 years. retiring 4 days afterof hygiene. 39 years. Additional 4 days of operatories hygiene. Additional operatories North Fresno. GrossNorth Receipts Fresno. in Gross2010 Receiptswere $173K. in 2010 $300K. were 1,975$173K. sq. ft. with$300K. 4 ops, 1,975 8 days sq. ft.hygiene/wk. with 4 ops, Digital, 8 days hygiene/wk.building hasDigital, two units.building One side has istwo designed units. Oneand sideplumbed is designed for and plumbed for days. Practice has beendays. in its Practice present has location been infor its past present 18 years. location foroperatories past 18 years.5 available. operatories Laser, Intra-Oral 5 available. Camera, Laser, Cerac, Intra-Oral & Camera,could be Cerac, added &to existingcould space. be added Great to location.#14376.existing space. Great location.#14376. Approximately 450 Approximatelyactive patients. 4503 operatories.active patients. Dentrix 3 operatories.Intra-Oral Dentrix Camera, Dentrix,Intra-OralSOLD Trojan, Camera, fiber Dentrix, optics, Trojan,P & C fiber dentistry optics, andP & the C other dentistry was a law and office. the other There was is a 3,776 law office. sq. ft. Thereof is 3,776 sq. ft. of Owner retiring. Owner retiring. Eaglesoft software. OwnerEaglesoft would software. like to retire.Owner #37108. would like to retire. #37108. software. Leased officesoftware. 1,200 sq. Leased ft. Owner office has 1,200 been sq. accepted ft. Owner to haschairs been accepted- all less tothan 5chairs years old.- all Ownerless than is 5retiring. years old. #14327 Owner is retiring.office space. #14327 The dentaloffice office space. is approximately The dental office 1,800 is sq. approximately ft. with 1,800 sq. ft. with • LEMOORE/HANFORD• LEMOORE/HANFORD AREA: For Sale-General AREA: Dentistry For Sale -General Dentistry an Endodontic Residencyan Endodontic after starting Residency practice after1 1/2 starting years ago. practice 1 1/2 years ago. 6 operatories. The 6building operatories. has beenThe buildingrecently hasre-roofed. been recently re-roofed. • EL DORADO HILLS:• EL DORADOFor Sale-General HILLS: dentistry For Sale- practice.General dentistry practice. • GREATER CHICO:• GREATER For Sale-General CHICO: Dentistry For Sale- Practice.General DentistryPractice Practice.& Building. PracticeOwner has& Building.worked in Owner this location has worked since in this location since • SACRAMENTO: • For SACRAMENTO: Sale-General DentistryFor Sale-General Practice. DentistryExcellent Practice. opportunity Excellent for a startup opportunity practice orfor for a startupthe dentist practice that or for the dentist that Gross Receipts of $834KGross with Receipts adj net of of $834K $389K, with 53% adj overhead. net of $389K, 53% overhead. Gross receipts in 2010Gross were receipts $584K, in with 2010 an were adjusted $584K, net with1971. an adjusted Gross Receipts net 1971.were $378KGross Receiptswith $139K were adj. $378K net income.with $139K adj. net income. • NORTHERN CALIFORNIA:• NORTHERN For CALIFORNIA:Sale-Endodontic ForPractice. Sale-Endodontic Practice. Gross Receipts $546K with adjusted net income of $159K. needs more space. Financing available through various dental Office has five equippedOffice operatorieshas five equipped in 1485 operatoriessq.ft. Pano, in 1485 sq.ft. Pano, Gross Receipts $546K with adjusted net income of $159K. needs more space. Financing available through various dental SOLD income of $152K. incomeApprox of1,100 $152K. active Approx patients. 1,100 4 activeThere patients. are 3 equipped4 There operatories are 3 equipped and 3 daysoperatories of hygiene. and 3 days of hygiene. This Endodontic practiceThis isEndodontic located in practicean upscale is locatedprofessional in an upscale professional Intra-oral Camera, Dentrix,Intra-oral 5 days Camera, of hygiene. Dentrix, Owner 5 days retiring. of hygiene. Owner retiring. Office is 2,400 sq ft Officewith 7 isoperatories. 2,400 sq ft Practice with 7 operatories.has been Practicelenders. has#14368 been lenders. #14368 operatories, Pano, Intra-Oraloperatories, Camera. Pano, Easy Intra-Oral dental Camera.software. Easy Purchase dental software. of the buildingPurchase is optionalof the buildingto the Buyer.is optional 100% to the Buyer. 100% office complex. The ownersoffice complex.condominium The ownersoccupies condominium 1,770 sq ft, occupiesoperating 1,770 in sqthe ft, same operating location infor the the same past location50 years. for Pano, the past 50 years. Pano, • FOLSOM: For Sale• -General FOLSOM: Dentistry For Sale Practice.-General Gross Dentistry Receipts Practice. Leased Gross office Receipts 1,200 sq.Leased ft. Owner office is 1,200retiring. sq. #14359.ft. Owner is retiring.financing #14359. is availablefinancing for both buildingis available and for practice. both building Excellent and practice. Excellent There are 4 equippedThere treatment are 4 rooms equipped with treatment an additional rooms 5th with anSoftdent additional software. 5th OwnerSoftdent to retire. software. #14374 Owner to retire. #14374• SANTA CRUZ: For• SANTA Sale-General CRUZ: Dentistry For Sale practice.-General GrossDentistry practice. Gross in 2010 were $703K inwith 2010 an adjustedwere $703K net incomewith an ofadjusted $300K. net 5 income of $300K. 5 opportunity for new gradopportunity or satellite for practice. new grad #14375. or satellite practice. #14375. room available. Grossroom Receipts available. were Gross $638K Receipts with $239Kwere $638K with $239K Receipts $300K with Receiptsa 57% overhead. $300K with Office a 57% is 1,140 overhead. sq. ft. Office 3 is 1,140 sq. ft. 3 days of hygiene and approx1500days of hygiene active and patients. approx1500 Leased active Office patients. • GREATER Leased Office SAN • GREATER JOSE AREA: SAN For JOSE Sale- AREA:General For Sale-General adjusted net income. Owneradjusted will net stay income. for transition Owner will to introduce stay for transition • SACRAMENTO/ROSEVILLE: to introduce • SACRAMENTO/ROSEVILLE: For Sale-One of many For Sale-equippedOne of operatories. many equippedIntra-Oral operatories. Camera, Pano, Intra-Oral Digital Camera, X-Rays, Pano, Digital X-Rays, is 2,000 sq ft with 4is equipped 2,000 sq operatories-5 ft with 4 equipped SOLDpossible. operatories-5 Patient Endodonticpossible. Patient Practice. 2009Endodontic Collections Practice. were 2009 $1,187MIL Collections with were • LINDSAY:$1,187MIL withFor Sale• LINDSAY:-General Dentistry For Sale Practice-General & Dentistrybuilding. Practice & building. buyer. Owner is retiring.buyer. #14251 Owner is retiring. #14251 partners is retiring in thispartners highly is successfulretiring in thisGeneral highly Dentistry successful Generaland Dentrix Dentistry software. and Practice SOLDDentrix has software. been in Practiceits present has location been in its present location Base software. OwnerBase to retire. software. Owner to retire. an adjusted net incomean adjustedof $696K. net There income are of4 ops$696K. in this There areGross 4 opsReceipts in this $330K Gross with Receipts adjusted $330K net income with adjustedof $219K. net income of $219K. Group Practice. Intra-OralGroup Practice.Camera, DigitalIntra-Oral Pano-Dexis, Camera, Digitalsince Pano-Dexis, 1980. Owner retiring.since 1980.#14358. Owner retiring. #14358. nicely decoreated 1,400nicely sq ftdecoreated office space. 1,400 4 sqmicroscopes. ft office space. Owner 4 microscopes. has operated inOwner present has location operated for in27 present years. Officelocation space for 27 years. Office space • NORTHERN CALIFORNIA:• NORTHERN For CALIFORNIA: Sale-Pediatric practice.For Sale -Pediatricelectronic practice. charts, ownerelectronic Financing. charts, Callowner for Financing. further Call for further • FOLSOM: For Sale• -General FOLSOM: Dentistry For Sale Practice.-General Gross Dentistry Receipts Practice. Gross Receipts Owner has been in sameOwner location has beenfor 26 in years same with locationSOLD long-term for 26 years1,489 with sq. long-term ft., 3 operatories 1,489 sq.available ft., 3 operatories(2 equipped), available Intra-Oral (2 equipped), Intra-Oral Owner has operated inOwner same locationhas operated for 32 in years. same Approxlocation 1,760 for 32 years.information. Approx 1,760 #14334 information. #14334 • SANTA CRUZ: •For SANTA Sale-General CRUZ: Dentistry For Sale practice.-General ThisDentistry practice. This in excess of 1.5M thein past excess three of years. 1.5M Adjusted the past threeNet of years. $550K. Adjusted Net of $550K. employees. Owner is retiringemployees. but willOwner continue is retiring to work but 1will ½ tocontinue Camera, to work Soft-Dent 1 ½ to software.Camera, 3-hygieneSoft-Dent dayssoftware. a week. 3-hygiene Owner days a week. Owner active pts, 1,160 sq activeft, panoramic pts, 1,160 X-Ray, sq ft, Dexis panoramic Digital X-Ray, and Dexis Digital and excellent practice is centrallyexcellent located practice in isa professionalcentrally located complex. in a professional complex. 2,700 sq. ft. office with2,700 7sq. ops, ft. Digital,office withDentrix, 7 ops, Intra-Oral Digital, Dentrix,2 years Intra-Oralthrough the transition2 years throughwith the the buyer. transition with the buyer. retiring. #14363. retiring. #14363. Dentrix software in thisDentrix 5–chair software office. in 2009this 5–chairGross Receipts office. 2009 Gross Receipts • SAN BERNARDINO: For Sale-General Dentistry Practice. Office is approx. 1,885 sq. ft., 4 operatories with room for one Camera, Laser, 5+yearCamera, old equipment, Laser, 5+year 8 days old hygiene.SOLD equipment, Beautiful 8 days hygiene. Beautiful SOLD • SAN BERNARDINO: For Sale-General Dentistry Practice. Office is approx. 1,885 sq. ft., 4 operatories with room for one $713K with 48% overhead.$713K Ownerwith 48% retiring. overhead. Call for Owner Details. retiring. CallGR for $972K. Details. Practice hasGR been$972K. in itsPractice present has location been in for its the present additional. location for There the are approx.additional. 2000 There active are patients approx. with 2000 6 activedays of patients with 6 days of office, great location. office,Owner great retiring. location. #14336 Owner retiring. #14336• HAWAII (MAUI):• HAWAIIFor Sale- General (MAUI): dentistry For Sale- practice.General •dentistry LIVERMORE: practice. For• LIVERMORE:Sale-General Dentistry For Sale Practice.-General 2009Dentistry Practice. 2009 past 35 years. Leased 4,500past 35 sq years. ft of officeLeased space- 4,500 12 sq equipped ft of office space-hygiene 12 equippedper week. Practicehygiene Pano, per week.Intra-Oral Practice Camera Pano, and Intra-Oral Easy Camera and Easy Gross Receipts of Gross$636K. Receipts Office ofhas $636K.four equippedOffice hasCollections four equipped were $688KCollections with an adjustedwere $688K net income with an of adjusted $287K. net income of $287K. For Sale-General Dentistry Practice. • OCEANSIDE: For• Sale OCEANSIDE:-Modern looking For Sale office.-Modern 4 op, lookingoffice office.operatories. 4 op, office Dentrix operatories.software, Pano Dentrix and software,Cerac. Accepts Pano and DentalCerac. software. Accepts OwnerDental is retiring. software. Reasonable Owner is leaseretiring. available. Reasonable lease available. • FOUNTAIN VALLEY:• FOUNTAIN For Sale-General VALLEY: Dentistry Practice. operatories in 1198 sq.ft.operatories Pano, inLaser, 1198 I.O.sq.ft. Camera, Pano, FiberLaser, I.O.There Camera, are 4 Fiberops in thisThere nicely are updated 4 ops in1,082 this nicelysq. ft. officeupdated space. 1,082 sq. ft. office space. Gross Receipts $284,000 with only a 47% overhead. Practice space and equipmentspace only. and Belmont equipment chairs. only. Gendex Belmont x-ray chairs. Gendex x-ray Gross Receipts $284,000 with only a 47% overhead. Practice Optics, 2 ½ days of hygiene.Optics, Owner2 ½ days retiring: of hygiene. Don’t Owner miss this retiring: Dentrix Don’t misssoftware, this 6-days/wkDentrix hygiene.software, Owner 6-days/wk hasSOLD beenhygiene. in same Owner has been in same HMO. Multi-specialtyHMO. practice. Multi-specialty Owner to relocate. practice. #14377 Owner to relocate.#14361 #14377 #14361 has been in its present location for the past 37 years. There are system, intraoral camera, approx 1200 sq ft. Low overhead-Rent has been in its present location for the past 37 years. There are opportunity to live andopportunity work in paradise. to live and#20101 work in paradise. #20101location for 36 yearslocation with long-termfor 36 years employees. with long-term Owner isemployees. Owner is system, intraoral camera, approx 1200 sq ft. Low overhead-Rent two equipped operatories in this 5 op office. E2 2000 software. two equipped operatories in this 5 op office. E2 2000 software. retiring. #14326 retiring. #14326 is $1,900/month, andis it's $1,900/month, a 5 year lease. and Staff it's ais 5available year lease. for Staff• SAN is available DIEGO: for For • Sale SAN-General DIEGO: Dentistry For Sale practice.-General Gross Dentistry • TORRANCE: practice. Gross For • TORRANCE:Sale-General DentistryFor Sale -Generalpractice. DentistryThis practice. This Doctor is retiring. SOLD Doctor is retiring. • HAYWARD: For • Sale- HAYWARD:General Dentistry For Sale- Practice.General ThisDentistry Practice. This rehire-front desk $15/hr,rehire-front assistant 13/hr.desk $15/hr, Update assistant all the computer 13/hr. Update Receipts all the computer $414K. PracticeReceipts has $414K.been operated Practice by has the been same operated excellent by the practice same is centrallyexcellent located practice in isa professionalcentrally located complex. in a professional complex. practice consists of 1,600practice sq ft consists with 4 treatmentof 1,600 sqrooms ft with in an4 treatment • LOS roomsANGELES: in an •For LOS Sale ANGELES:-General Dentistry For Sale Practice.1,200-General Dentistry sq Practice.1,200 sq systems after purchasingsystems the afteroffice purchasing in 07. Computers the office andin 07. ownerComputers for the and past 6 years.owner Leasedfor the 950past sq.6 years. ft. office Leased with 950 3 sq.Office ft. office is approx. with 3 1,885Office sq. ft., is approx.4 operatories 1,885 withsq. ft., room 4 operatories for one with room for one For Sale-General Dentistry IV Sedation Practice. • FRESNO: For Sale• -General FRESNO: Dentistry IV Sedation Practice. excellent location. 2010excellent Gross location.was $501,000 2010 withGross a was$228K $501,000 ft 4ops, with a29 $228K yrs in presentft 4ops, location. 29 yrs Gross in present Receipts location. $274K Gross with Receipts $274K with monitors in every room.monitors #14346 in every room. #14346 equipped operatories.equipped Dentix software,operatories. Intra-Oral Dentix camera,software, Intra-Oraladditional. camera, There are approx.additional. 2000 There active are patients approx. with 2000 6 activedays of patients with 6 days of (MERGER OPPORTUNITY) Owner would like to merge his SOLD (MERGER OPPORTUNITY) Owner would like to merge his adjusted net income. Dentaladjusted Vision net income. software, Dental AverageSOLD Vision age software, of adjusted Average net age income of ofadjusted $89K. Ownernet income to retire. of $89K. #14348 Owner to retire. #14348 Panoramic X-Ray. OwnerPanoramic to relocate. X-Ray. #14356. Owner to relocate. #14356.hygiene per week. Practicehygiene Pano, per week.Intra-Oral Practice Camera Pano, and Intra-Oral Easy Camera and Easy practice into another high quality general dentistry or IV practice into another high quality general dentistry or IV equipment is 8 yrs. Approximatelyequipment is 81,200 yrs. Approximatelyactive patients. 1,200 active patients. • PLEASANTON: For• PLEASANTON: Sale-General Dentistry For Sale Practice.-General Owner Dentistry Practice. Owner Dental software. OwnerDental is retiring. software. Reasonable Owner is leaseretiring. available. Reasonable lease available. sedation practice. Thesedation merger practice. would beThe into merger Buyers would office. be into Buyers office. • MARIN COUNTY:• MARINFor Sale -GeneralCOUNTY: Dentistry For Sale Practice.-General This Dentistry Practice. This has other practice in Bayhas Areaother only practice in Pleasanton in Bay Area 1 day/wk. only in Pleasanton300 • SAN 1 day/wk. DIEGO: 300 For • Sale- SANGeneral DIEGO: Dentistry For Sale- Practice.General 6 Dentistryops, #14320 Practice. 6 ops, #14320 Seller would like to continue to work as either a partner or Seller would like to continue to work as either a partner or • IRVINE & COSTA• IRVINE MESA: &For COSTA Sale-General MESA: Dentistry For Sale- Generalis a small Dentistry 650 sq.ft. isoffice a small with 650 three sq.ft. treatment office withrooms. three The treatment rooms. The active patients. Excellentactive location-beautiful patients. Excellent 1600 location-beautiful sq.ft. 5-op Intra-Oral1600 sq.ft. camera, 5-op EagleIntra-Oral Soft Software. camera, EagleOffice Soft square Software. feet Office square feet associate after the merger. 2010 collections were $993K with a associate after the merger. 2010 collections were $993K with a practice combined. Grosspractice receipts combined. combined Gross $781K receipts with combined practice $781K has witha very lowpractice overhead has a ofvery only low 48%. overhead 2010 ofgross only 48%. 2010 gross office. Equipment likeoffice. new, Equipment intra-oral likecamera, new, pano, intra-oral Easy camera,2,300 pano, with 3Easy years remaining2,300 with on 3lease. years 2009 remaining Gross onReceipts lease. 2009• TORRANCE: Gross Receipts For • Sal TORRANCE:e - General DentistryFor Sale -Practice. General GrossDentistry Practice. Gross $422K adjusted net income. There are 7 days of hygiene. $422K adjusted net income. There are 7 days of hygiene. adjusted net of $396K.adjusted Both officenet of spaces$396K. are Both leased office with spaces receipts are leased were with $179,000 receipts with were$90,000 $179,000 adjusted with net. $90,000 Practice adjusted net. Practice Dental software. MustDental See. #14364. software. Must See. #14364. $1,448,520, with an adjusted$1,448,520,SOLD net incomewith an ofadjusted $545K. net Doctor income ofReceipts $545K. $413K Doctor with Receipts an adjusted $413K net with income an adjustedof $203K. net 50% income of $203K. 50% #14250. #14250. 4-5 ops in each. Both 4-5are 1,600ops in sq. each. ft. IrvineBoth are is equipped1,600 sq. withft. Irvine includes is equipped Panoramic with X-rayincludes and PanoramicEasy Dental X-ray Software. and Easy Refers Dental out Software. Refers out would like to phase outwould then likeretire. to #14331phase out then retire. #14331 overhead. Practice hasoverhead. been in its Practice present has location been infor its the present past 25 location for the past 25 Intra-Oral Camera, PanoIntra-Oral & Dentrix. Camera, Costa Pano Mesa & isDentrix. equipped Costa MesaO.S., Perio.,is equipped & Endo. PracticeO.S., Perio., has been& Endo. in its Practice present has location been infor its present location for • PLUMAS COUNTY:• PLUMAS For Sale-3 COUNTY: equipped ops. For SpaceSale-3 available equipped ops. Space available years. The office has beenyears. tastefully The office remodeled. has been tastefully Office is remodeled.800+ Office is 800+ FACILITY SALE-General Dentistry Office Space • GLENDALE: FACILITY• GLENDALE: SALE-General Dentistry Office Space with Laser, Intra-Oralwith Camera, Laser, Pano Intra-Oral and Dentrix. Camera, #14355. Pano and Dentrix.30 years. #14355. This is an ideal30 years. practice This for is thean idealnew gradpractice or satellite for the new grad or satellite for 4th op. 1,245 sf foroffice 4th inop. good 1,245 location. sf office Gross in good Receipts location. • SANTA Gross ReceiptsBARBARA: • SANTA For Sale BARBARA:-General Dentistry For Sale Practice.-General Dentistrysq. ft. with Practice. 3 equipped sq. operatories. ft. with 3 equipped 4 -hygiene operatories. days per week.4 -hygiene days per week. & Leasehold Improvements Sale- Office located in a medical & Leasehold Improvements Sale- Office located in a medical practice for the establishedpractice dentist. for the Owner established is retiring. dentist. #14370 Owner is retiring. #14370 $475K. Practice in present$475K. location Practice over in present 50 years. location Owner over is 50 Thisyears. excellent Owner practice’sis This 2009 excellent gross practice’s Receipts 2009$891K gross with Receipts Doctor $891K is to retire.with #14369Doctor is to retire. #14369 plaza, 1760 sq. ft. 7 operatories, computerized equipment plaza, 1760 sq. ft. 7 operatories, computerized equipment • LAGUNA NIGUEL:• LAGUNA For Sale- General NIGUEL: Dentistry For Sale- Practice.General Dentistry Practice. retiring. #14318 retiring. #14318 steady increase everysteady year. Practiceincrease hasevery 6 daysyear. of Practice hygiene. has 6 days of hygiene. approximately 5 yearsapproximately old. Two 5-year 5 yearsoptions old. available. Two 5-year #14373 options available. #14373 2010 gross receipts2010 were gross $503k. receipts 4 operatories, were $503k. Pan, 4 • operatories, MODESTO-TRACY-STOCKTON Pan, • MODESTO-TRACY-STOCKTON AREA: For Sale-Pediatric AREA: For Sale-Pediatric 1,690 sq. ft., 5 ops, Laser,1,690 Intra-Oral sq. ft., 5 ops,Camera, Laser, Schick Intra-Oral Digital Camera, • TRACY: Schick ForDigital Sale-Equipment, • TRACY: furnishings,For Sale-Equipment, and leaseholds furnishings, only. and leaseholds only. computerized with EZcomputerized dental software. with 1,500 EZ dental sq. ft. software.lease. 10 1,500Practice. sq. ft. lease. $677,000 10 inPractice. collections $677,000 in 2010 in with collections a $357,000 in 2010 net with a $357,000 net • RENO: For Sale•-General RENO: DentistryFor Sale -GeneralPractice andDentistry Dental Practice X-Ray, and Datacon Dental software. X-Ray,SOLD Doctor Datacon has software.been practice Doctor in samehas been Inpractice the Central in same Valley. In Fullythe Central equipped Valley. including Fully 4equipped Belmont including 4 Belmont • GRASS VALLEY:• For GRASS Sale-General VALLEY: Dentistry For Sale- Practice.General GR Dentistry of Practice. GR of years in present location.years Owner in present retiring. location. #14352 Owner retiring. #14352income. This 3-chair officeincome. is Thislocated 3-chair in approximately office is located 1,250 in sqapproximately 1,250 sq Building: 2009 Gross Building:Receipts $517K2009 Gross with adjustedReceipts net$517K income with adjustedlocation net for income the past locationeleven years for theof hispast 31 eleven years years in Santa of his 31Accutrac years in chairs, Santa 2 MidmarkAccutrac chairs, chairs, 6 DCI2 Midmark rear delivery chairs, units, 6 DCI 3 rear delivery units, 3 $307,590 (3 days/wk)$307,590 with adjusted (3 days/wk) net income with adjustedof $105K. net 3 income of $105K. 3 ft & has recently beenft remodeled. & has recently Patient been Base remodeled. software. Patient Office Base software. Office of $165K. 4 ½ hygieneof days/week. $165K. 4 ½ 1, hygiene 800 sq. ft.days/week. with 6 equipped 1, 800 sq. ft.Barbara. with 6 equipped Doctor is retiring.Barbara. #14333 Doctor is retiring. #14333 Gendex x-ray units, 1Gendex Soridexdigital x-ray units, x-ray 1 processor,Soridexdigital 1 Statim x-ray processor, 1 Statim Ops. refers out most/allOps. Ortho. refers Perio, out most/all Endo, Surgery. Ortho. Perio,Intra-Oral Endo, Surgery. Intra-Oral • For LAKE Sale- COUNTY:General Dentistry For Sale- Practice.General Dentistry Practice. SOLD • LAKE COUNTY: equipped for NO2 &equipped IV sedation. for NO2Practice & IVhas sedation. operated Practice in its has operated in its ops. (7 Avail). Dentrixops. software,SOLD (7 Avail). Pano. Dentrix Practice software, has been Pano. in itsPractice has been in its 5000, 1 Harvey autoclave.5000, 12,800 Harvey Sq autoclave.ft, 6 Ops. 2,800 New Sqlease ft, 6 Ops. New lease Camera, Diagnodent,Camera, EZ Dental Diagnodent, Software. EZ Good Dental Location. Software. GrossGood ReceiptsLocation. 904K Grosswith adjusted Receipts net 904K $302K. with Practiceadjusted has net $302K. Practice has present location for 20present years. location for 20 years. present location for 40present years. locationOwner retiring for 40 years. Owner retiring• SAN LUIS OBISPO:• SAN For LUIS Sale OBISPO:- Two Doctor For SaleGeneral - Two availableDoctor Generalfrom landlord. available #14335. from landlord. #14335. Owner retiring. #14337.Owner retiring. #14337. been in same locationbeen for past in same 23 yrs, location and 25 for yrs past in previous23 yrs, and 25 yrs in previous Dentistry Practice. GrossDentistry receipts Practice. $1,537,142 Gross for receipts 2010 with$1,537,142 for 2010 with location. 2,600 sq ftlocation. with 8 2,600equipped sq fttreatment with 8 rooms.equipped • treatment NEWPORT rooms. BEACH: • NEWPORT For Sale -General BEACH: Dentistry For Sale Practice.-General Dentistry Practice. For Sale-General Dentistry Practice. GR • ROCKLIN: For • Sale ROCKLIN:-General DentistryFor Sale -GeneralPractice. DentistryGross anPractice. adjusted Grossnet income an of adjusted $691K. netThe income office hasof $691K. 2,331 sq. The ft. office • VISALIA: has 2,331 sq.For ft. Sale- • General VISALIA: Dentistry For Sale- Practice. General Gross Dentistry Receipts Practice. Gross Receipts • GRASS VALLEY:• For GRASS Sale- GeneralVALLEY: Dentistry Practice. GR Intral-Oral Camera, Pano,Intral-Oral and Data Camera, Con software. Pano, and Owner Data Conto software.Practice Owner has operated to Practiceat its present has operated location atsince its present 1986. Located location since 1986. Located 545K 3 days/wk (4 avail). 3 hygiene days/week. 5 Ops (6 Avail) Receipts $593K in 2010Receipts with $593K $240K in adjusted 2010 with net $240Kincome. adjusted with net8 equippedincome. operatories.with 8 equipped Pano, E4D,operatories. and Dentrix Pano, E4D,$616K and with Dentrix an adjusted $616K net income with an of adjusted $ 321K. net Office income is 1,380 of $ 321K.sq Office is 1,380 sq 545K 3 days/wk (4 avail). 3 hygiene days/week. 5 Ops (6 Avail) retire. #14338 retire. #14338 in a highly affluent inNewport a highly Beach affluent community. Newport ThreeBeach (3)community. Three (3) 1,950 sq ft. Refers out most/all Ortho, Perio, Endo, Surgery. Office is 1,630 sq. ft.,Office with is4 operatories1,630 sq. ft., equipped with 4 operatorieswith fiber equippedsoftware. with Practice fiber startedsoftware. in 1990 Practice and has started been inin 1990its present and has beenft with in its 3 present equipped ftoperatories, with 3 equipped Intra-Oral operatories, Camera, DigitalIntra-Oral Camera, Digital 1,950 sq ft. Refers out most/all Ortho, Perio, Endo, Surgery. hygiene days per week.hygiene Leased days office per space week. with Leased 4 ops. office in 1,450 space with 4 ops. in 1,450 Office has Laser, Intraoral Camera, Pano, &• Dentrix LANCASTER: Software. For • Sale- LANCASTER:General Dentistry For Sale- Practice.General This Dentistry 4 Practice. This 4 SOLD optics. Owner has beenoptics. inSOLD present Owner location has been for in the present past 13 location years. for locationthe past 13since years. 1998. locationApprox. since3000 1998.active Approx.patients. 3000 Great active X-Rays, patients. Mogo Great software, X-Rays, equipmentSOLD Mogo software,& leaseholds equipment look new. & leaseholds5 look new. 5 Office has Laser, Intraoral Camera, Pano, & Dentrix Software. sq. ft. Pano & Practicesq. Works ft. Pano software. & Practice #14354. Works software. #14354. Owner retiring. #14372.Owner retiring. #14372. operatory office is locatedoperatory in 2,360 office Sq isFt located on the secondin 2,360 floor Sq Ft on the second floor 3 1/2 days hygiene. Intra-Oral3 1/2 days Camera, hygiene. Dentrix Intra-Oral software. Camera, Owner Dentrix location software. with Owner nice views.location #14353. with nice views. #14353. years in present location.years Owner in present to relocate. location. #14347 Owner to relocate. #14347 to retire. to retire. CALIFORNIA / NEVADA REGIONAL OFFICE CALIFORNIA / NEVADA REGIONAL OFFICE HENRY SCHEIN PPT INC. Henry Schein PPT Inc., Real Estate Agents California Regional Coporate Office and Transitions Consultants DR. DENNIS HOOVER, Broker Office:(800) 519-3458 Office (209) 545-2491 Dr. Tom Wagner (916) 812-3255 N. Calif. Mario Molina (323) 974-4592 S. Calif. Fax (209) 545-0824 Email: [email protected] Jim Engel (925) 330-2207 S.F./Bay Area Thinh Tran (949) 533-8308 S. Calif. PROFESSIONAL PRACTICE TRANSITIONS 5831 Stoddard Road, Ste. 804 Modesto, CA 95356 jan. 12 classifieds
cda journal, vol 40, nº 1
classifieds, continued from 82 opportunity available — practices. The Ostrow School of Dentistry opportunity available — General Excellent part-time, (evenings and Master in Orofacial Pain and Oral private dental practice seeking for an Saturdays), opportunity for a highly Medicine program is a three-year online associate dentist who can deliver quality qualified Cosmetic/General Dentist. program designed to give dentists a service for our patients. Must be able to Dentist must be highly skilled in all phases deeper understanding of treating patients do ALL phases of dentistry including of Endo. Our well established multi-spe- with mouth and facial pain, sleep-disor- posterior RCT and extractions. Must be cialty practice is conveniently located in dered breathing, oral and maxillofacial able to work on Saturdays. Please fax or San Francisco’s Financial District. Contact infections, temporomandibular joint email your resume attention to Ted Mr. Steck at 415-874-4336. disorders, and other complex issues that Teodoro (office manager) at [email protected] affect the mouth and face. Designed for or 510-245-3004. opportunity available — Univer- practicing full-time dentists the curricu- sity of Southern California Ostrow School lum involves video lectures, weekly live opportunity available — OM with of Dentistry Master of Science in video conferences of patient cases, a high sense of purpose to work in relation- Orofacial Pain and Oral Medicine A new short visit to campus each summer, and ship-based practice with no insurance program at the Ostrow School of Den- the preparation of a research article. To contracts built on a purpose of wellness. tistry of USC will allow dentists to enrich learn more about the new online Master High sense of ethics, excited about the idea their clinical skills - all from the conve- in Orofacial Pain and Oral Medicine of utilizing her exquisite talents in further- nient location of their own dental Program please email [email protected]. continues on 88 Journal_half_horiz_social_media copy.pdf 1 12/23/11 10:15 AM
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86 january 2012 “MATCHING THE RIGHT DENTIST TO THE RIGHT PRACTICE”
Complete Evaluation of Dental Practices & All Aspects of Buying and Selling Transactions
3060 SACRAMENTO COUNTY GP General & Cosmetic practice located in the charming, picturesque town known as "The Jewell of Sacramento County". For those who enjoy cycling, running and other outdoor activities. The American River parkway winds through this town and can be ridden all the way to Folsom Lake. Beautifully &PENDING thoughtfully designed, this well appointed office has 6 fully equipped ops with state-of-the-art equipment and facility. The practice is located in a single occupancy, free standing, single story professional building of approximately 2,000 sq. ft. The building's lot has ample on-site parking and is located on a major Serving you: Mike Carroll & Pamela Gardiner thoroughfare with fantastic visibility. Approximately 1,500 current/active patients (all 3069 NAPA VALLEY ENDO fee-for-service) with an estimated 16 new patients Endodontic practice now available in Napa a month. 2010 GR $1.6M with an adjusted net Valley. Gorgeous state-of-the-art 1,450 sq. ft. income of almost $500K. Asking price $950K. facility w/4 fully-equipped ops & microscope in every op. Single story professional building. Well- 3064 SAN JOSE GP established w/seasoned & loyal staff. Avg. GR Now available. Great turnkey opportunity. over $1M past 3 years w/4.5 doctor days. Beautiful 1,500 sq. ft. facility with 4 fully Excellent referral sources and upside opportunity. equipped ops. State-of-the-art fully networked office, Dentrix software, digital x-ray & recently 3049 SAN JOSE GP purchased dental & office equipment. Avg. GR Well-located, across from O'Connor Hospital, $328K+ with 4 doctor-days. Owner relocating general practice in 2,118 sq. ft.state-of-the-art out of the area. Asking $220K. facility w/ 3 fully-equipped ops. 2 pvt. offices (1 can be plumbed for 4th op.). This office is 3065 FREMONT GP beautifully designed and is stunning. In addition Don't miss this opportunity. Spacious 1,150 sq. ft. to his general practice, owner treats sleep apnea office w/ 3 ops. No Capitation. 2010 GR 169K+ patients. He is selling just the general operative w/ just 2-2.5SOLD doctor days. Perfect opportunity to portion of the practice and is willing to help for a take this practice to the next level. Owner smooth transition. Ideal for an experienced retiring. Asking $124K. dentists looking to merge an existing practice. Asking $195K. 3057 SAN JOSE GP Priced to sell. Located in 2 story professional 3059 SANTA CRUZ COUNTY GP & BDG building w/3 fully-equipped ops. in 990 sq. ft. Charming practice tucked among soaring office. Part of historic Rose Garden redwoods in Santa Cruz County. Located in a neighborhood;SOLD 1 block from the Alameda, & single level professional building in the heart of near a well travelled intersection. Seller Contact Us: town. Well established and part of the small transitioning due to health reasons. FY 2010 GR Carroll & Company $415K. Asking Price $120K. community landscape. 2010 GR $595K+ w/3 2055 Woodside Road, Ste 160 doctor days. All fee-for-service. Owner retiring Redwood City, CA 94061 and willing to help for a smooth transition. This 3052 PETALUMA GP is a great turn key practice and opportunity to Well-established 3 Dr. day practice in 2,268 sq. own a hidden gem. Practice asking price $373K, ft. office w/6 ops. Avg. gross receipts for past 3 Phone: building is also available. years $315K. Located just a mile from the 650.403.1010 Petaluma RiverSOLD in the historic town of Petaluma. 3061 SAN JOSE DENTAL FACILITY Centrally located 32 miles north of SF in the Email: Dental facility ideal for Pediatric or easily Sonoma County Wine Country. Bldg. is available [email protected] converted to GP. Located in desirable Evergreen for purchase. Asking $145K. area in a two-story, handicap accessible, high Website: profile, medical and professional building. Gross Upcoming: www.carrollandco.info lease with utilities included expires July 2013 CA DRE #00777682 with 5 year option to renew. Modern, tastefully 3068 MONTEREY COUNTY GP designed, approximately 1,321 square feet. Asking $95K.
jan. 12 classifieds
cda journal, vol 40, nº 1
classifieds, continued from 86 ing the practice purpose. Protocols to nity area. Various pay option and flexible and I am currently in Scottsdale, AZ, so I reverse decay & perio disease; rehabilitative to work at clean office. Email j9dds@ can quickly be wherever needed when the treatment w natural esthetics & healthy oral yahoo.com or call 323-567-9999. right opportunity arises. I am looking for function. Time allotted towards pt ed a long-term relationship in a high quality, regarding pt role in attaining optimum oral opportunity available — Our 2 op patient centered office. Email tamjag@aol. health via HC skill development & high office is looking for a dental assistant and com or call 480-634-8568. involvement with individual health a BILINGUAL [Spanish] receptionist. protocols. TMJ-related migraines, head/ Experience is preferred but we will be opportunity wanted — Are you neck problems tx’d with workable, long welcoming applicants who need training. thinking about retiring? Want to make sure term solutions. Recognition/rewards based Office is open M-F Please email or fax your patients are well taken care of? Female on unique contributions. Not suited for resume with references to meltemd3@ GP, UOP grad, looking for a general practice job-seeker but an individual career oriented, yahoo.com or call 805-481-3363. in the Pleasanton, Dublin or San Ramon confident in talents & in an earnest search area. Ideally looking for a practice grossing for an opportunity to express it. Practice is opportunity available — Full time between $ 500,000-$750,000 annually. I am owner occupied in unique & quaint area. Dentist with experience to work on a prequalified buyer willing to pay above the Please only sincere, qualified applicants pediatric pts. 5 years old and older. Most appraised price for the right practice. Please respond via resume to mcbridedds@aol. work is restorations, Pulpotomies, & contact [email protected] for com. Website authored by practice owner: stainless-steel crowns. Email dr.mg@ more info. www.longbeachholisticdentist.com. bachour.org or call 209-723-5005. opportunity wanted — In the Great- opportunity available — Summary seeking managing dentists — If er San Francisco Bay Area. Implant of Essential Job Functions: Sterilize and you’re looking for a long-term commit- Surgery/Bone Grafting/Perio Surgery/3rd disinfect instruments and equipment. ment and desire to be productive the Molar Extractions. Email bayareaperio@ Prepare treatment rooms, instruments opportunity is yours! Seeking full-time, gmail.com or call 617-869-1442. and tray setups for dental procedures. managing dentists to join large group Greet and prepare patients for treatment. practice in the following areas: Los opportunity wanted — General Take digital radiographs Assist the dentist Angeles, Orange County, Inland Empire, dentist with over 8 years experience looking during examinations and treatment San Diego and doctors willing to relocate for FT/PT position. Available to cover for procedures. Conduct work in compliance to Arizona. Steady patient flow in high maternity leave, vacations, and any other with office policies and procedures, safety, volume HMO environment. Required: 3-5 time off. Location: Sacramento and and OSHA guidelines. Record medical yrs experience and proficient in molar surrounding areas including Roseville, and dental histories and vital signs of endo. Benefits include: medical, dental, Rocklin, Lincoln, and Yuba City. For more patient. Record treatment information in vision, 401K, malpractice coverage and information, please feel free to contact me patient records. Participate in the achieve- competitive pay! For available positions at 916-580-3945 or email aicha_benbrahim@ ment of patient satisfaction and office please call: 714-428-1305, submit your hotmail.com. production goals by working efficiently resume to kristin.armenta@smilebrands. and providing a high level of patient com or fax to 714-460-8564. opportunity wanted — Do you want service. Assist with other duties as to increase your revenue and work fewer directed from the Permitted Duties. opportunities wanted hours? Are you thinking of selling your Provide patient education materials. practice? Do you have a unique opportu- Maintain an appropriate office environ- opportunity wanted — After over nity where you need a dentist? I am an ment. Minimum Requirements Current 20 successful years, I sold my upscale, experienced, professional, compassionate, CPR Certification Radiation Safety private practice and I am looking to efficient dentist relocating to the Bay Area Certificate (x-ray license) Good communi- relocate to CA. Let me e-mail you my list after the New Year looking for employ- cation skills. Ability to perform detailed of advanced CE courses I have attended, ment opportunities. I am open to work acco. Email yourladentist@gmail. as well as testimonials and photos from associating, purchasing, covering leave, com or call 310-482-3971. my previous patients. This will let you get consulting, full-time or part-time employ- to know a little about me, as well as the ment or any other opportunity. CV and opportunity available — Looking high quality of restorative and cosmetic references readily available. I look forward for Spanish speaking dentist. Able to work dentistry I can provide. I have an excellent to hearing from you! Email farahanidds@ general dentistry and productive in chair side manner, my patients and staff gmail.com or call 206-293-7915. well-civilized Spanish speaking commu- really know I care. I have my CA license, continues on 90
88 january 2012 Professional Practice Sales of The Great West
If you want your practice “For Sale”, we are not the rm for you. If you want your practice “SOLD”, contact us!
5999 “SOLD” PLEASANTON Adjacent to Hacienda Business Park. 2011 6013 “SOLD” LIVERMORE Not yet 4-years old, tracking $430,000+ in tracking $900,000. Strong profits. Digital radiography with collections 2011. Attractive 4-Op suite fully networked, employs computers in Ops. Great visibility. computer charting and digital radiography. 6003 “SOLD” PINOLE - HERCULES AREA 4-days of Hygiene. 90%+ effective 6014 “SOLD” SAN FRANCISCO Located in “Heart” of the Mission. Owner Recall. Produced $740,000 and collected $709,500. Low AR balance. does not speak Spanish. 2011 tracking $425,000+ with $185,000 in Endo referred. Profits on 3-day week. 3-Ops. Great opportunity for Successor who 6004 “SOLD” SAN JOSE’S SANTA TERESA AREA Asking slightly more shall devote more attention. Building has private garage for tenants. than what it would cost to replicate this office today. Digital & 6015 SONOMA COUNTY’S HEALDSBURG Vibrant economy and great paperless 3-Op suite. 2010 produced $385,000 with collections of small town atmosphere. Anchored by 4-day per week Hygiene $277,000 and Profits of $190,000+. Gorgeous facility. Lease allows schedule and great Office Manager. Revenues tracking $545,000 occupancy thru 9/30/2024. with Profits of $235,000 in 2011. 6008 MENDOCINO COAST - FORT BRAGG Nestled in desirable cultural 6017 CAMPBELL 2011 shall collect $600,000. Adec delivery systems, haven creates attractive lifestyle. 4-days of Hygiene. 2011 shall top computer charting, digital radiography, Biolase Waterlase, $700,000 in collections making this its best year ever. Owner works Panorex. $380,000 invested here. Full price $350,000. 3-day week and states he could work more if desired. Computerized Ops and digital radiography. 6018 SAN JOSE’S CAMPBELL Senior partner in esteemed Group 6010 “SOLD” BERKELEY – ALTA BATES MEDICAL VILLAGE Attractive Practice is retiring. Produced $460,000 and collected $420,000 in revenues. Last 2-years Profits have averaged $225,000. 2011 2010 with Profits of $190,000+. Great opportunity to simply treat doing better! patients and go home as Administrator oversees all front-end operations. Full price $230,000. 6011 “SOLD” SAN JOSE – WEST OF I-280 Long established practice off Saratoga Avenue. Has averaged $400,000 per year in collections. 6019 ALAMEDA Best location, adjacent to upscale neighborhoods. 3-Ops with 4th available in 1,000 sq. ft. suite. Owner works relaxed pace. Attractive 2-Op office with 2-more Ops available. Excellent upside. Asking price warrants immediate 6012 “SOLD” FREMONT Well established practice as evidenced by 6+ investigation. days of Hygiene. Fantastic Recall System. Great location. Collects just shy of $900,000 per year. Total Available Profits in 2010 were 6020 "COMING UP" - PEDO PRACTICE - SACRAMENTO AREA Generates $360,000. 5-Ops. $500,000 per year. Beautiful office. Shall be available shortly. For complete details on any of these opportunities, go to www.PPSsellsDDS.com Professional Practice Sales of The Great West Ray and Edna Irving (415) 899-8580 ~ (800) 422-2818 www.PPSsellsDDS.com Thinking on selling your practice? Call “PPS of The Great West” today. This shall be the best decision you make regarding this important change in your life!
“I listed with a competitor for 12 months. Had two people visit my “When I signed the Listing on June 1st, Ray stated he would have the practice sold by Labor Day. The sale was concluded on Sept 1st, two days before Labor Day. Wow!” step of my life.” “I will always remember your statement when I questioned your contract “It was a pleasure to work with PPS. I had to sell because of health being only four months. You stated: ‘If I can’t sell your practice in that time, you complications. Mr. Irving listed my practice on Jan 1st, we closed escrow on should get someone else.’ Well, you did with time to spare!” Feb 27th. It took him less than 60 days to complete the sale as promised.” “Before I called Ray, I had a listing with another prominent Broker. After eleven months without a sale, I called Ray. He sold it in about a month! Would I “When I decided to sell my ortho practice, I sought the services of a recommend Ray? Yes!” large company. Over the 12-month contract, I had one buyer visit. Word “In April, I asked Ray Irving to sell my practice. At the same time my friend
My regret was the time and money lost with the other guys.” My friend’s practice still hasn’t sold and he was putting his dreams on hold.”
provide the best service imaginable for this very important engagement.
CA DRE License #1422122 jan. 12 classifieds
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classifieds, continued from 88 dental practices for sale
practice for sale — General Practice dental office with a 40 plus year history of goodwill in the Sacramento, CA. area looking to find a wonderful, kind practi- Paul Maimone tioner to purchase practice. The office is Broker/Owner HAPPY NEW YEAR! conveniently located in a highly visible, easily accessible professional building BAKERSFIELD #21 - (10) op G.P. & Bldg. on a main St. (3) ops fully eqt’d. (3) ops part eqt’d with close proximity to an upscale retail & (4) add. Plmbd. Store front. Collects ~$500K/yr. Cash/Ins/PPO/< l % Denti-Cal. NEW. mall. The office occupies approximately CENTRAL VALLEY/So. FRESNO CTY. - (3) op compt. G.P. Newer eqt., digital x-rays & 1,200 sq. feet and consists of 4 fully Dentrix s/w. Limited competition. Cash/Ins/PPO. New bldg out in 2009. SOLD COVINA #2 - (4) op comput. G.P. (3) ops eqt’d 4th plmbd. Mixed pt base. 2010 Gross Collect equipped ops (+ 1 additional plumbed), a $250K on a 3 day wk. Can rent space or buy 2,150 sq ft duplex bldg. REDUCED AGAIN reception area, a doctor’s office, a business COVINA #3 - (3) op compt. G.P. Cash/Ins/PPO. Gross Collect $242K+ on an easy (3) day wk. office, a sterilization area, a staff lounge, a Located in a small prof/medical/dental bldg. w off street parking. Seller retiring. NEW th lab, and restroom. The practice generates GLENDALE #6 – (5) op state of the art comput. G.P. 4 ops eqt’d, 5 op plumbed. Digital x-ray approximately 12-15 new patients per & networked. Mixed pt base. In a free stand bldg. Annual Gross Collect.~ $500K. L.A. (SILVERLAKE - ATWATER) – (3) op G.P. located in the trendy Silverlake-Atwater area. month. The doctor will work back in the (28) years of Goodwill. Cash/Ins/PPO. Gross Collect $140K p.t. Retail Store front. NEW practice or mentor (if desired) to help the th NEWPORT BEACH - (5) op comput. G.P. 4 ops eqt’d/5 plmbd. In a prof. bldg. on the Marina. new doctor with a successful transition. Cash/Ins/PPO small % cap. Dentrix & Shick. Collects $400K+ on a (2) day wk. NEW This is only at the request of the purchas- No. COUNTY SAN DIEGO - (4) op comput G.P. in a shop ctr. w excell exposure & signage. Cash/Ins/PPO/HMO pts. Dentrix s/w, paperless & digital. Gross Collections $900K+/yr. ing dentist. The practice is located in a OXNARD #5 - (4) op comput G.P. Can purchase w or w/o single use free stand. bldg. Mixed pt great community in which to live and base. 2011 Project Gross Collect $447K. Locate on a heavily traveled main Rd. REDUCED practice dentistry. Please send your CV to: RESEDA #6 - (3) op comput G.P. located in a well know, easily accessible prof. bldg. Cash/Ins/PPO pts. Annual Gross Collections ~ $150K on a p.t. schedule. [email protected]. SANTA BARBARA #2/GOLETA - (4) op computerized G.P. located in a garden style prof. bldg. w St. frontage. (3) ops eqt’d/4th plumbed. Cash/Ins/PPO pt. base. (4) days of hygiene/wk., practice for sale — One of the most approx. (20) new pts/mos. Pano eqt’d. Collects. $400K+/yr. on a (4) day wk. REDUCED respected practices in Ventura County SANTA BARBARA #3 - (3) op comput. G.P. in a prof/med/dental bldg. Cash/Ins/PPO. 8-10 new pts/mos Gross Collect. $250K+ on a (4) day wk. Digital x-ray. Seller retiring. REDUCED with 41 years of good will. Loyal staff of UPLAND #3 - (5) op comput G.P. & Speciality Pract. in a free stand bldg. Gross Collect $525K- eight and an associate of two years. 4 ops., $625K/yr. Digital x-ray. Excell opp. for G.P. who likes to do Endo. BACK ON MARKET 1 op equipped for implants. Fully comput- VACAVILLE – (3) op compt. G.P. turnkey w charts. Shunted 5 mos. Great start up op. NEW erized, digital X-rays and cameras. WEST HILLS - (3) op compt G.P. in a prof. bldg. Newer leaseholds. Cash/Ins/PPO. Digital x- rays & Dentrix s/w. 2010 Gross Collect. ~ $305K part time. Seller retiring. PENDING $860,000 annual collection. Buyer must UPCOMING PRACTICES: Camarillo, Corona, Covina, Irvine, Long Beach, Montebello, have a love for dentistry and a good sense Panorama City, Pasadena, SFV, San Diego, Thousand Oaks, Torrance, & West L.A. of humor. Email [email protected] or D&M SERVICES: call 805-486-6327. Ŷ Practice Sales & Appraisals Ŷ Practice Search & Matching Services Ŷ Practice & Equipment Financing Ŷ Locate & Negotiate Dental Lease Space Ŷ Expert Witness Court Testimony Ŷ Medical/Dental Bldg. Sales & Leasing Ŷ Pre - Death and Disability Planning Ŷ Pre - Sale Planning P.O. Box #6681, WOODLAND HILLS, CA. 91365 Toll Free 866.425.1877 Outside So. CA or 818.591.1401 Fax: 818.591.1998 www.dmpractice.com CA DRE Broker License # 01172430
CA Representative for the National Association of Practice Brokers (NAPB)
90 january 2012
cda journal, vol 40, nº 1
advertiser index
A. Lee Maddox, A Professional Law Corporation maddoxpracticegroup.com 37
California Practice Sales calpracticesales.net 80
CariFree carifree.com 30
Carroll & Company Practice Sales carrollandco.net 87
CDA Membership cda.org/member 8–9
CDA Practice Support Center cdacompass.com 16–17
D&M Practice Sales and Leasing dmpractice.com 90
DOCS Education docseducation.com 11
Golden State Practice Sales 925-743-9682 82
Implant Direct implantdirect.com 38
Lee Skarin and Associates, Inc. leeskarinandassociates.com 91
Leonard Smith, DDS ddsworkshop.com 63
Maddox Practice Group maddoxpracticegroup.com 7
Paragon Dental Practice Transitions paragon.us.com 47
Professional Practice Sales of the Great West 415-899-8580 89
Professional Practice Transitions pptsales.com 84–85
Select Practice Services, Inc. betterobin.com 95
The Dentists Insurance Company tdicsolutions.com 2, 12
TOLD Partners, Inc. told.com 81
Ultradent Products ultradent.com 96
Western Practice Sales/John M. Cahill Associates westernpracticesales.com 6, 35, 83
for advertising information, please contact corey gerhard at 916-554-5304.
92 january 2012
jan. 12 dr. bob
cda journal, vol 40, nº 1
dr. bob, continued from 94 makes sense; you’re in bed anyway, The parade will re-form up for a concert. so multiple rest periods requiring no “How do you like working the night preparation other than squirming, offer before long to ascertain shift?” I asked Sandy, who is assigned to something to look forward to. caring for any needs I have — other than Here comes the blood delivery lady whether I’ve disturbed any sleep — at 4:30. and her spooky accomplice, looming up “Fine,” she said, “It’s calmer around silently out of the Stygian shadows. Both of the tubes, wires and here at night.” are bearing hand-held scanners, since “Really? I … ” everything including the urinal is bar- cables while trying to find an “You get used to it,” she interrupted, coded. Efficiency is the keynote. In less elusive comfortable position anticipating my question. time than it takes to wonder why this Maybe, but the most basic thing — is being done at such an ungodly hour, in this high-tech bed. that of getting a morning bath — may they complete their scanning, hookup, take a little more getting used to. Back disassembly, and record-keeping to make in the day when modesty and dignity way for the next cheerful night person, were more de rigueur, a bath in a hospi- Maria, the blood removal lady. asked my name, DOB and disposition to tal setting featured a washcloth handed Maria, RN, is unnaturally cheerful at allergies. I don’t have any allergies, which to the patient with the firm understand- this hour for anybody except vampires. is an obvious disappointment as there is a ing it was for a specific reason. Today She skillfully extracts approximately place for noting them on my chart. a hospital bath is a marvel of precision the same amount of donated blood the It is rest time again. The parade will and efficiency. The thing closest to it is preceding crew has just given me. I am a re-form before long to ascertain wheth- the Penske Racing Team changing tires middle-man for the recycled blood busi- er I’ve disturbed any of the tubes, wires at a 20-second Indy 500 pit stop. ness. I mention this to this nice lady and cables while trying to find an elu- Zip! goes a shower cap impregnated with the needle. “Ha, ha,” she convulses, sive comfortable position in this high- with shampoo over my head. A team as if never having heard this observa- tech bed. It pulsates periodically in an member approaches from either side tion before. unnerving fashion as if I had acquired of the bed. In a move only capable of Diplomacy and tact are surely two of an inquisitive ferret as a bedmate. being recorded in slo-mo by high-speed the most necessary courses on the cur- All this activity is accomplished very cameras, the bed sheets are whisked riculum at nursing school. On a Tuesday quietly. It is necessary in night-time from beneath me, replaced and I have in 1859, Florence Nightingale stated, “It hospital protocol to maintain a funereal been scrubbed from head to toe — like may seem a strange principle to enunci- silence for two reasons: (1) your rest is completely — without any of my as- ate as the first requirement in a hospital important to you and (2) staff needs to sistance. Blotted dry and whisked into it should do the sick no harm.” One can clearly hear the gong/beep/buzzer sys- a clean, backless gown, it wasn’t until have a morning face like 10 miles of tem that replaces verbal communication later that I realized I had surrendered bad road, bed hair resembling Bozo the between you, them and the machines my last vestige of human dignity — and clown and the demeanor of a rodeo bull tethered to you. worse yet, I kind of enjoyed it! and these Florence Nightingales of St. What could go wrong? Everything, If you ever wish to be treated like roy- Jude will greet you each morning with apparently. The urgency of the GBB alty, actually be patiently and cheerfully honeyed assurance that “you’re lookin’ System’s messages is abundantly clear waited upon by people who are thought- good” just as if you weren’t, in fact, the to the nursing staff that interprets the ful, kind, gentle and probably underpaid, whiniest, most disruptive and demand- sounds by their frequency, volume and I recommend spending a few days in a ing patient to ever be admitted. degree of irritation. The machines talk modern hospital. Just don’t expect to be By 4:30, the queue diminishes once to each other as well; one device eager cured of insomnia. the EKG guy has completed his survey to report another device’s failure or pass and the drip-pack replenishment nurse on a request for maintenance. The total tidies up and dematerializes. All of them result is a nocturnal symphony not un- have scanned my color-coded wrist bands, like a Jamaican steel drum group tuning
january 2012 93 Dr. Bob cda journal, vol 40, nº 1
My Dream: To Sleep
She skillfully extracts “Robert?” I awoke suddenly from a fit- also is aware of the 10 EKG leads snak- ful sleep, searching near-sightedly about ing out from under my air-conditioned approximately the the dimly lit room. From the doorway, a hospital gown. narrow slit of light widened as a hushed “Shhh. Time for your temperature,” same amount of donated voice again queried, “Robert?” Denise quietly replied, ignoring me. “Yeah, yeah, Denise. What can I do for During the next four hours at this blood the preceding crew you this time?” hospital (Motto: We Never Sleep — Nor “Robert Horseman?” the gentle voice Shall You), other ghostly figures waft in has just given me. replied. “Date of birth?” and out. Their mission is either to give “Three-eleven-twenty,” I sighed. you something, or to take something Squinting at the big clock on the wall — from you, frequently both at the same , Robert E. near as I could tell without my glasses time. Hospitals believe in rest — lots of Horseman, — it was a little after one o’clock in the it. Unlike the dedication to the magic morning. number “eight” most of us feloniously DDS “Denise, what’s the matter with you? profess to observe, e.g., eight hours of illustration You’ve asked me that 16 times a day for sleep, eight glasses of water and eight by dan hubig the last five days. I’m tethered to a bed hours of work, hospitals like to divide 4½ feet off the floor with IV drips in both the rest period up into as many as 16 arms and compression booties wrapped increments of a half-hour each. This around my legs.” Denise knows this. She continues on 93
94 january 2012 When you want your practice sales DONE RIGHT.
Dr. Robin’s upcoming speaking engagements. Call us for more details.
January 19th, 2012 - Southern California Oral/Facial Study Club; Tarzana; Dental Practice Act.
March 4th, 2012 - Loma Linda University, Loma Linda; Dental Practice Act.
May 3rd, 2012 - California Dental Association, Anaheim Session; Dental Practice Act.
December 2nd, 2012 - Loma Linda University, Loma Linda; Dental Practice Act.
BetteRobin,DDS, JD DENTIST ATTORNEY BROKER Loma Linda Dental 83 Southwestern Law 95
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