http://www.nytimes.com/2007/10/11/business/11decay.html?pagewanted=print

October 11, 2007
Boom Times for Dentists, but Not for Teeth
By ALEX BERENSON

For American dentists, times have never been better.

The same cannot be said for Americans’ teeth.

With dentists’ fees rising far faster than inflation and more than 100
million people lacking dental insurance, the percentage of Americans
with untreated cavities began rising this decade, reversing a
half-century trend of improvement in dental health.

Previously unreleased figures from the Centers for Disease Control and
Prevention show that in 2003 and 2004, the most recent years with data
available, 27 percent of children and 29 percent of adults had
cavities going untreated. The level of untreated decay was the highest
since the late 1980s and significantly higher than that found in a
survey from 1999 to 2002.

Despite the rise in dental problems, state boards of dentists and the
American Dental Association, the main lobbying group for dentists,
have fought efforts to use dental hygienists and other non-dentists to
provide basic care to people who do not have access to dentists.

For middle-class and wealthy Americans, straight white teeth are still
a virtual birthright. And dentists say that a majority of people in
this country receive high-quality care.

But many poor and lower-middle-class families do not receive adequate
care, in part because most dentists want customers who can pay cash or
have private insurance, and they do not accept Medicaid patients. As a
result, publicly supported dental clinics have months-long waiting
lists even for people who need major surgery for decayed teeth. At the
pediatric clinic managed by the state-supported University of Florida
dental school, for example, low-income children must wait six months
for surgery.

In some cases, the results of poor dental care have been deadly. A
child in Mississippi and another in Maryland died this year from
infections caused by decayed teeth.

The dental profession’s critics — who include public health experts,
some physicians and even some dental school professors — say that too
many dentists are focused more on money than medicine.

“Most dentists consider themselves to be in the business of dentistry
rather than the practice of dentistry,” said Dr. David A. Nash, a
professor of pediatric dentistry at the University of Kentucky. “I’m a
cynic about my profession, but the data are there. It’s embarrassing.”

A defender of the profession is Dr. Terry D. Dickinson, a practicing
dentist who is also the executive director of the Virginia Dental
Association. He says he believes that dentists are charitable and want
to provide care to poor patients. But dentists are also in business;
they must pay rent and employee salaries, and they deserve fair fees,
he said.

“Charity is not a health care system,” Dr. Dickinson said.

Dentists, of course, are no more obligated to serve the poor than are
lawyers or accountants. But the issue from a public health standpoint,
the critics say, is that even as so many patients go untreated,
business is booming for most dentists. They are making more money
while working shorter hours, on average, even as the nation’s number
of dentists, per person, has declined.

The lack of dental care is not restricted to the poor and their
children, the data shows. Experts on oral health say about 100 million
Americans — including many adults who work and have incomes well above
the poverty line — are without access to care.

A federal survey shows that 27 percent of adults without insurance saw
a dentist in 2004, down from 29 percent in 1996, when dental fees were
significantly lower, even after adjusting for inflation. For adults
with private insurance, the rate was virtually unchanged, at 57
percent, up from 56 percent. Since 1990, the number of dentists in the
United States has been roughly flat, about 150,000 to 160,000, while
the population has risen about 22 percent. In addition, more dentists
are working part time.

Partly as a result, dental fees have risen much faster than inflation.
In real dollars, the cost of the average dental procedure rose 25
percent from 1996 to 2004. The average American adult patient now
spends roughly $600 annually on dental care, with insurance picking up
about half the tab.

Dentists’ incomes have grown faster than that of the typical American
and the incomes of medical doctors. Formerly poor relations to
physicians, American dentists in general practice made an average
salary of $185,000 in 2004, the most recent data available. That
figure is similar to what non-specialist doctors make, but dentists
work far fewer hours. Dental surgeons and orthodontists average more
than $300,000 annually.

“Dentists make more than doctors,” said Morris M. Kleiner, a
University of Minnesota economist. “If I had a kid going into the
sciences, I’d tell them to become a dentist.”

But despite the allure of rising salaries, the shortage of dentists
will almost certainly worsen, because the nation has fewer dental
schools and fewer dentists in training than a generation ago. After
peaking at 5,750 in 1982, the number of dental school graduates fell
to 4,440 in 2003, as several big dental schools closed their doors.
The average dentist is now 49 years old, according to the American
Dental Association, and for at least the next decade retiring dentists
will probably outnumber new ones.

Even if more students wanted to enter the profession, states are not
moving aggressively to expand dental schools or open new ones.
Training dentists is expensive, because dental schools must provide
hands-on training — unlike medical schools, which send doctors to
hospitals for training after they graduate. Hospitals receive federal
subsidies for the training they provide to medical interns and
residents, but the equivalent system does not really exist in
dentistry.

Meanwhile, the A.D.A. does not support opening new dental schools or
otherwise increasing the number of dentists. The association says it
sees no nationwide shortage of dentists, though it acknowledges a
shortage in rural areas. Dentists note that in the early 1980s, when
schools were graduating nearly twice as many dentists relative to the
overall size of the population as they are now, some dentists
struggled to keep their practices afloat.

Dr. Kathleen Roth, president of the A.D.A., said that the association
is working to increase Medicaid’s reimbursement rates to make it more
cost-effective for dentists to treat low-income patients. While
Medicaid is supposed to cover both basic care and emergency procedures
for children, the program will pay only for emergency procedures — not
basic care — for adults in most states.

“Access to dental care, especially for children, has been a growing
problem for 10 years,” Dr. Roth said. “State and federal programs have
decreased the amount of dollars available.”

Besides calling for higher Medicaid reimbursement, Dr. Roth said, the
association supports putting health aides with basic dental training
into public schools. The aides would help get appointments for
children who need them and teach children basic habits like brushing
teeth.

But critics say the association’s plans would do little to solve the
basic problem of access to care. Moreover, even in states that have
raised Medicaid payments, most dentists still do not accept Medicaid
patients. Virginia, for example, overhauled its Medicaid program in
2005, raising rates 30 percent. But only about 25 percent of all
Virginia dentists now accept Medicaid patients, compared with 15
percent before the changes.

Some dentists do not accept Medicaid patients because they frequently
miss appointments, which means lost revenue, said Dr. L. Jackson
Brown, the former managing vice president for health policy at the
A.D.A.

With little dental care available for poor children, pediatricians are
teaching themselves how to apply fluoride varnish on baby teeth, a
simple procedure that can prevent cavities, said Dr. Amos S. Deinard,
a pediatrician and associate professor at the University of Minnesota.

“The dentists don’t want to see these kids,” Dr. Deinard said.

Outside the United States, more than 50 countries, including some
western European nations, now allow technicians called dental
therapists to drill and fill cavities, usually in children.

Proponents of the therapists say their training is comparable to the
practical training that dentists receive, but without the general
medical training dentists get. Studies of the work performed by the
therapists have concluded that it is comparable to, and in some cases
better than, that of fully trained dentists.

Dr. Frank Catalanotto, a professor of community dentistry at the
University of Florida, said dental therapists would be a
cost-effective way to provide basic care to children and some adults
who could not otherwise afford treatment.

But state boards of dentistry have blocked dental therapists from
working, arguing that only dentists should be allowed to drill teeth,
because it is an “irreversible surgical procedure” and can lead to
serious complications like infections or nerve damage. Children of
Alaska Natives in remote areas have high rates of cavities and
essentially no access to dentists, so a coalition of tribes began a
program in 2003 to use therapists to treat native children.

“There’s never been a dentist in these rural areas,” said Dr. Ron
Nagel, a dentist who helped create the Alaska program.

But the American Dental Association fought the program almost as soon
as it began, dropping its effort only in July, after a state judge
ruled in favor of the program. Still, the group continues to oppose
letting dental therapists practice anywhere in the continental United
States.

“What we’re extremely uncomfortable with is that they need to drill
teeth and sometimes extract teeth,” said Dr. Roth, the association’s
president. Use of therapists would create a two-tier system where some
people have access to dentists, while others must settle for
less-qualified practitioners, she said.

Dr. Caswell A. Evans, a dentist and associate dean at the University
of Illinois-Chicago, said dentists must stop fighting efforts to
expand care to patients they are not currently treating. The system is
failing many patients, he said.

“Right now we have a double standard of care,” Dr. Evans said. “Some
people can get it and some people can’t.”