OPTIMAL DELIVERY OF ORAL HEALTH SERVICES THROUGH PRIMARY CARE:
A Comprehensive Workforce Policy Statement
Academy of General Dentistry (AGD)
In 2008, the Academy of General Dentistry (AGD) published the “White Paper on Increasing Access to and Utilization of Oral Health Care Services,” calling for the implementation of twenty-five proven methods of improving access to and utilization of oral health care services, from Medicaid improvements and loan forgiveness programs, to oral health literacy and strengthening the dental workforce. In 2012, the AGD’s “Barriers and Solutions to Accessing Care” identified solutions to key areas that presented challenges to the delivery of care, including oral health literacy, converting literacy to action, moving from a treatment mentality to a prevention mentality, social and cultural misperceptions, the economics of sustainable care delivery, distribution of provider populations, and addressing patients with special needs.
Despite the various needs that must be addressed to improve oral health in the United States, state legislation has focused on the issue of workforce, thanks to a few vocal groups that have devoted significant resources solely to the promotion of alternative workforce models that utilize lesser-trained non-dentists to provide surgical care to the most vulnerable populations, in a manner that is neither cost-effective nor shown to have produced positive population health outcomes. As the American Dental Association (ADA) stated in “Breaking Down Barriers to Oral Health for All Americans: The Role of Workforce” (2011), we are “disappointed in… the degree to which the fixation on workforce, a deceptively ‘simple’ issue to grasp, has distracted policymakers and those who influence them from the much greater number and complexity of other barriers to care.”
Therefore, the AGD’s “Optimal Delivery of Oral Health Services through Primary Care: Comprehensive Workforce Policy Statement” (Statement), presented here, does not purport to identify the numerous barriers to care, nor does it purport to offer all their solutions. However, the purpose of this Statement is to present a cohesive perspective on the synergy and symbiosis of the dental workforce required for the optimal delivery of oral health care in the United States.
Executive Summary Statement
In medicine, the diversification of the workforce away from primary care and toward a proliferation of nurse practitioners and specialists has burdened the taxpayer with increased cost of care and has adversely affected patient health.1 Conversely, 80% of the delivery of oral health care is provided through primary care – via general and pediatric dentists – enabling a focus on prevention that mitigates more serious and costly health conditions.
The AGD, along with the ADA, the American Academy of Pediatric Dentistry (AAPD), and other professional organizations, have long touted this philosophy of prevention through the concept of the dental home. “The dental home is the ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way. Establishment of a dental home begins no later than 12 months of age and includes referral to dental specialists when appropriate” (AAPD, Policy on the Dental Home, 2012).
Unfortunately, many children, especially those who are poor or live in rural communities, have not seen a dentist by the age of 12 months. Moreover, visits to a dentist decline significantly in adult populations.2 The inclusion of pediatric dentistry but exclusion of adult dentistry in the Essential Health Benefits (EHB) prescribed by the Patient Protection and Affordable Care Act (PPACA) may drive benefits allocations that further distort this statistic. Failure to see a dentist for preventable diseases has produced a heavy cost burden on emergency rooms across our nation. Additionally, economic woes such as unemployment may provoke migration of patient populations that may further affect the longevity and continuity of the relationship between a given dentist and patient. Moreover, the morphology of the dental practice is a complex and unpredictable study, as economic and other considerations drive the eruption of group practices and corporate practices. The AGD’s “Investigative Report on the Corporate Practice of Dentistry” (AGD Practice Models Task Force, 2013), presented many of these complexities and unknowns.
Therefore, while the dental home is at the heart of optimal oral health care delivery, a broader and more cohesive workforce concept must be defined to address the needs of the many who may meander their way into the oral health care system, if at all, through emergency rooms, medical practitioners, public schools, or knowledgeable friends, family members, or others in their communities. This concept is the “dental team concept.” The dental team concept is a comprehensive and optimal primary care model of oral health care delivery, under the supervision of a licensed dentist, and with the dental home at its core.
The following diagram provides a visual representation of the dental team concept to include a snapshot of contemporary considerations in the delivery of oral health care and the role of the dental home therein. However, the points of entry or other representations in the diagram are not intended to be limiting in the scope of the concept or in the position of the AGD.
General Supervision: The level of supervision in which dentist is not present in the dental office, but has authorized the procedures and they are being carried out in accordance with his/her diagnosis and treatment plan.
Indirect Supervision: The level of supervision in which the dentist is in the dental office, authorizes the procedure and remains in the dental office while the procedures are being performed by the auxiliary.
Direct Supervision: The level of supervision in which the dentist is in the dental office, personally diagnoses the condition to be treated, personally authorizes the procedure and, before dismissal of the patient, evaluates the performance of the dental auxiliary.
Personal Supervision: The level of supervision in which the dentist is personally operating on a patient and authorizes the auxiliary to aid his/her treatment by concurrently performing a supportive procedure
Dental Auxiliaries – Persons including dental assistants, dental hygienists, dental laboratory technicians, expanded function dental assistants or hygienists, and dental therapists or other ‘midlevel providers’ in states where they are sanctioned by law, and all other individuals who are not licensed dentists, but otherwise provide oral health care.
Dental Home - “The ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way. Establishment of a dental home begins no later than 12 months of age and includes referral to dental specialists when appropriate” (AAPD, Policy on the Dental Home, 2012)
Dental Team Concept - A comprehensive and optimal model of oral health care delivery, with a focus on primary care dentistry under the supervision of a licensed dentist, and with the dental home at its core.
The AGD believes that the dental team concept provides the optimal model of oral health care delivery, and further, that the dental team concept must be consistent with the following workforce principles:
The dental home, where dental services are provided only by or under the direct or indirect supervision of a licensed dentist, is the core principle of the dental team concept regardless of the economic or rural status of the patient, or the size, structure, or business agreements of the dental practice.
Dental procedures that are surgical and irreversible must only be administered by a licensed dentist (personal supervision) and not relegated to an auxiliary. A procedure is surgical and irreversible if an attempt of performance of the procedure carries with it any risk of an irreversible adverse consequence. Therefore, excavation of decay would fall within a surgical and irreversible procedure.
Increased number and use of auxiliaries within the dental home, including expanded function auxiliaries, whereby the auxiliaries act only within the direct or indirect supervision of the licensed dentist when providing dental services, increases the capacity of the dental home.
Dental disease is preventable, and prevention creates a lesser cost burden to the patient and the public than treatment. Accordingly, resources should be dedicated to establishing patient navigators within communities, whereby the duties of patient navigators are increasing oral health literacy, converting literacy to action, and providing patient transportation, and not the provision of dental care without the education and license of a dentist.
Emergency department dentistry adds a significant economic cost to the patient and the public, and must be mitigated by use of the dental home. Accordingly, the dental team concept requires collaboration between hospitals, medical practitioners, and the dental home, to ensure a transition of the patient from a treatment cycle to a prevention focus. The dental team concept requires referral to and follow-up care by the dental home after dental-related visits to medical practitioners or hospitals, and continued communication between the dental home and patients’ medical practitioners.
Any agreements between a dental practice and outside entities for the management of business or practice services must not, directly or indirectly, transfer clinical decisions to one who is not a dentist licensed in the state. Indirect transfer is a transfer that could result from provisions that place necessary clinical decision-making for optimal patient care in conflict with business protocols for continued employment or income of the practicing dentist or auxiliaries.
The dental team concept consolidates the oral health care needs of the patient through the dental home, and therefore, provides continuity to the patient’s care. Where access and utilization have been identified as challenges, this consolidation creates a lesser burden on the patient to know where to go for care. On the other hand, increased specialization and implementation of unsupervised or generally supervised practitioners operating outside of the dental home, fragments care and places the burden on the patient to seek multiple points of entry into the oral health care system. In the dental team concept, the general or pediatric dentist serves as a gatekeeper of referral needs and the central nervous system of the patient’s oral health care network.
In considering the current debate concerning the dental workforce, the AGD remains vigilant in its recognition that patient needs for better oral health, for quality care, and for treatment by those who are sufficiently educated to provide proper care, cannot be compromised. Further, as an organization of dedicated and educated professionals with a responsibility to the public, the AGD strongly feels that it would be negligent to refer this responsibility to the political tides of each state legislature. The AGD believes its core principles and values are in the best interest of its patients and the profession and is pleased to have had this opportunity to address the evolving face of dentistry, and find a cohesion within that evolution to enable dentistry to expand its reach as the beacon for low-cost patient-first preventive healthcare in the United States.
The Academy of General Dentistry
Position Statement on the Advanced Dental Hygiene Practitioner (ADHP) Concept
AGD Dental Practice Council, February 2008
Approved, AGD HOD, July 2008
In 2001, Oral Health in America: A Report of the Surgeon General unveiled a maldistribution in access to dental care across socioeconomic geographies. The Academy of General Dentistry (AGD) is dedicated not only to correcting the maldistribution in access to dental care, but furthermore, to providing non-discriminatory access to quality dental care.
In 2003, the AGD was the first dental professional organization to enter into a Memorandum of Understanding (MOU) with the U.S. Department of Health and Human Services (HHS) in an effort aimed at eliminating oral health disparities, increasing the public’s understanding of oral health issues, and expanding access to and utilization of dental care services. Other federal health agencies signing the MOU included the Centers for Disease Control and Prevention (CDC), the Office of Public Health and Science, the Health Resources and Services Administration (HRSA), the Indian Health Service (IHS), and the National Institutes of Health’s (NIH) National Institute for Dental and Craniofacial Research (NIDCR).
In its endeavor to eliminate oral health disparities, the AGD has engaged in federal lobbying and state advocacy efforts to support Medicaid and SCHIP programs, and funding thereof. Additionally, the AGD has supported the funding of Title VII dental residency programs. Further, the AGD has promoted patient education, and worked to eliminate impediments to competitive payment by third party payers, include Medicaid contractors, to dentists serving socio-economically disadvantaged populations. Moreover, the AGD encourages its approximately 35,000 members and all general dentists to volunteer their services to needy persons through programs such as Donated Dental Services and Give Kids a Smile. Further, AGD volunteers participate through the Special Olympics provider directory to provide services to persons with intellectual disabilities.
The thread that ties all of the AGD’s endeavors on access to care, and constructs the very fabric of the AGD’s belief, is that underserved and needy populations deserve the same quality of dental care as all Americans. Simply stated, reserving a lower quality of care for those facing depressed or oppressed socioeconomic conditions creates a separate and unequal standard to which the underserved are undeserved.
Advanced Dental Hygiene Practitioner (ADHP)
What is an ADHP?
The ADHP, a concept developed by the American Dental Hygienists’ Association (ADHA), is one of numerous concepts for midlevel dental workforce models which have been introduced as solutions to the challenge of offsetting the maldistribution in access to care. According to the ADHA’s Draft Competencies for the Advanced Dental Hygiene Practitioner (“Draft Competencies”), released in June 2007:
The ADHP is proposed as a cost-effective response to the oral health crisis. The ADHP will work in partnership with dentists to advance the oral health of patients. This new practitioner will provide diagnostic, preventative, therapeutic and restorative services to the underserved public in a variety of settings and will refer those in need to dentists and other healthcare providers. P.6.
How does the ADHP differ from other allied dental models?
While the ADHP may work in partnership with dentists, the ADHP concept is designed for independent practice. Unlike alternative allied dental models, such as Alaska’s Dental Health Aide Therapists (DHAT) and the American Dental Association’s (ADA) proposed community dental health coordinator (CDHC), an ADHP may work without direct, indirect, or general supervision by a dentist, and without any standing orders or dentist review. That is, the ADHP may fall completely outside the scope of the dental team concept.
However, what appear to be simple fillings or simple extractions may become complicated. For example, a simple filling may open into the nerve of a tooth, presenting an opportunity for the development of an abscess, which, if improperly treated, may become life-threatening. Without the immediate availability and resources of a dental team, the ADHP may be unable to avail himself or herself of the expertise and services of a dentist within the appropriate timeframe to provide the patient with the necessary care.
According to AGD policy, “the AGD supports the dental team concept as the best approach to providing the public with quality comprehensive dental care.” Dentistry, unlike medicine, has its focus on preventative care. The dental team concept provides the patient with a dental home for continuity of comprehensive care with a focus on prevention and treatment to mitigate the need for critical care.
On the other hand, ADHP’s will likely find it less economically feasible to maintain an independent practice without a dentist in the more underserved areas. These underserved areas may include remote rural areas or areas with high indigent populations who are most in need of dental care but least able to pay for it. The dental team concept, with the dentist in direct or indirect supervision of the practice, provides the hygienist with the economic protection and freedom to expand his or her practice to serve the needs of low-income populations through expanded services such as the provision of hygiene education and case management services (especially in the public health setting). Further, the team concept provides the accessibility to the knowledge and resources needed to address complications and compromised systemic health conditions that often plague the indigent and presently underserved.
Additionally, the ADHA’s Draft ADHP Competencies note that independent ADHPs would establish collaborative relationships with dentists and their dental teams, including traditional hygienists, and further, would refer their patient to the dentists as they deem appropriate. However, given the finding that there may be a maldistribution of dentists in underserved areas, access to opportunities for aforementioned collaboration and referral may meet the same challenge as the patients’ access to quality care itself. That is, without dentist supervision through a dental team concept, the independent midlevel provider may only serve the patient as an intermediary of time and money lost, not of care gained.
How does an ADHP differ from a dentist?
Without any dentist supervision or oversight, the ADHP purports to offer comprehensive oral health care in an independent setting except where the ADHP deems that referral to a dentist is needed. As noted above, the comprehensive oral health care purports to include diagnostic, surgical, and irreversible restorative services. In fact, the ADHA’s Draft Competencies cite an excerpt of the American Dental Educators Association (ADEA) report, Unleashing the Potential, which reads, “the dental hygienist can substitute for the dentist where there is none.” P. 7.
Given that the unsupervised practice of an ADHP would mirror that of a dentist in the services provided, inclusive of diagnoses and irreversible procedures that are presently reserved for dentists, one must examine whether the education and training of the ADHP meets the minimal competencies required of the dentist in the performance of the same procedures.
The ADHA proposes an ADHP master’s degree curriculum to provide the hygienist with the competency required to provide diagnostic, therapeutic, preventative, and restorative services. However, notwithstanding that there is currently no Commission on Dental Accreditation (CODA) approved ADHP master’s degree program, dental school curricula designed to graduate DDS recipients are structured only to meet the minimum standards for competency in dentistry as set by ADEA for CODA accreditation. Competency achieved through graduate dental education toward a DDS or DMD degree sets the floor, and not the ceiling, for the practice of clinical dentistry. If these are the minimum standards, anything less could not render a practitioner competent to perform dentistry.
Therefore, an ADHP master’s degree curriculum, regardless of CODA accreditation, cannot meet the minimum standards of competence to provide dentistry, especially diagnostic and irreversible dentistry, unless the ADHP master’s degree curriculum were to adopt the prerequisites of dental school entry and meet or exceed the competencies achieved through dental school. That is, the ADHP master’s degree candidate would essentially have to earn a dentist’s degree to qualify as a practitioner of the aforementioned dental procedures.
Since the educational framework proposed by the ADHA is intended to fall short of comprehensive dental school curricula, the quality of care provided by an ADHP would fall short of the minimal competency required of a dentist. One could argue that the benefit of competent care in dentistry is already a commodity only available to those who can afford it, and that those who cannot afford it presently get nothing. However, it is the AGD’s position that those who cannot afford dental care nonetheless deserve the same quality and competence of care as all.
Further, provision of a lesser quality of care to poorer populations conveys the illusion of care to the patient who might believe that the intermediate patchwork of a midlevel provider is sufficient while in fact clinical care by a dentist is required. Notwithstanding the inherent injustice in providing lesser quality (and potentially unsafe) care to more needy patients, one must also consider that disadvantaged populations have often neglected their dental health for years, thereby causing complications not as readily prevalent in the more advantaged communities. Further, lower quality patchwork dentistry, without the benefit of dentist supervision or a dental team home, may conceal underlying medical concerns and undermine dentistry and healthcare’s growing effort to address dentistry as a doorway for prevention of numerous systemic ailments.
How does the ADHP differ from advanced nurse practitioners?
The ADHA draws upon the advanced nurse practitioner model as setting precedent for the ADHP model. However, the ADHP and advanced nurse practitioner differ fundamentally in the models in which they practice, or intend to practice.
The dental concept and medical concept are vastly different. In the medical concept, the patient’s first contact is just the “point of entry.” Rich with diagnostic codes, the medical model focuses on a first diagnosis at the patient’s “point of entry,” and often a second or third diagnosis based upon the direction of referral. Therefore, in the medical model, the first diagnosis, regardless of by whom, merely opens the gateway to further evaluation, and need not disturb subsequent diagnosis or continuity of care
On the other hand, dentistry has served its patients quite well through a “dental team concept,” rather than a “point of entry” concept. The dental team concept serves the function of dentistry and patients’ access to care with its focus not merely on diagnosis of dental diseases, but rather, on prevention and continuity of care through treatment. That is, in dentistry, the “point of entry” is the point of prevention and treatment, and not just a segue, thereby saving time and cost.
Further, treatment by a dental team varies within acceptable standards of care based upon the assessments, competencies and preferred methodologies of the core dentist. Therefore, fragmentation of diagnosis or preliminary treatment shall not only fragment the dental team concept and dentistry’s holistic view of treatment, but also access to consistent quality care. That is, care shall be rendered discontinuous.
Therefore, while one can appreciate the medical model’s efforts at a solution to access to care with the adaptation of the nurse practitioner, a similar model would likely have the opposite effect in dentistry; that is, it would disrupt continuity of care and access to quality of care for patient populations.
Access to Quality Care, In Summary
Defining the challenge in providing access to quality care is the first step to addressing the challenge. Access to quality care has two components: access and quality. Quality is necessary to ensure patient safety.
Accessibility without quality echoes the “something is better than nothing” approach to care. However, this approach serves only injustice, and not the public need. A court of law does not provide an indigent defendant with a paralegal if he or she cannot afford an attorney. Likewise, accessibility in dentistry is meaningless without equivalent quality care.
Creation of the ADHP concept offers a divergence from the goal of access to quality care. The additional education required under the ADHP model provides students who might otherwise pursue a DDS or DMD with an avenue to spend time and money to earn a title that signifies the ability to provide a quality of care that falls short of the minimum competence required to practice dentistry, especially as related to diagnosis and irreversible procedures. Further, without the minimal education of a dentist, the ADHP may compromise the safety of the patient, and raise questions of assignment of liability.
Additionally, an ADA study1 revealed that, when provided the opportunity to practice independently to serve the needy, the overhead of maintaining a practice drives independent midlevel practitioners away from underserved areas. Presuming that the pilot study serves as a microcosm, the ADHP concept would fail to provide any indigent care, even that which falls short of the minimal standards of quality and safety. On the other hand, if the ADA study does not serve as a just microcosm, the practice of dentistry by one who has not attained the minimal qualifications of a dentist would nonetheless fall short of said minimal standards.
Given that dentistry, unlike medicine, has a focus on prevention and treatment, and is therefore best served by a point-of-service approach, the AGD supports the dental team concept as the best methodology to providing quality comprehensive care to all patients. The AGD also recognizes socio-economic divisions in the maldistribution in access to care. However, the AGD understands that underserved populations are at the greatest risk for oral and systemic disease, at the greatest need for high-quality comprehensive dental care and continuity of care, and therefore, least served by intermediate patchwork that may mask the recognition of a need for comprehensive care.
As stated above, the AGD is a leading proponent of making the dental team concept, with dentist supervision, accessible as a cornerstone of quality comprehensive care for underserved populations. The AGD has worked vigorously with state and federal agencies, dental schools, and other avenues to promote public funding, volunteerism, and loan forgiveness for dental students working in underserved areas, among numerous other efforts. However, the ADHP concept offers a diversion of focus, direction, and resources from these efforts, and an opportunity for separate and unequal care, if any, for populations that deserve the same quality as all Americans.
Brown, L.J., House, D.R., & Nash, K.D. The Economic Aspects of Private Unsupervised Hygiene Practice and Its Impact on Access to Care. Dental Health Policy Analysis Series. American Dental Association, 2005
Referring Dental Patients to Specialists and Other Settings for Care General Guidelines
Appropriate referrals are part of complete, quality health care management. Dentists' predoctoral training in oral diagnosis and treatment planning teaches them that referrals are an essential part of managing their patients healthcare needs. Dentists are expected to recognize the extent of their patient's treatment needs and when referrals are necessary. These Guidelines address the mechanics of dental referrals. They assume the dentist has the requisite skill and knowledge in diagnosis and treatment planning to determine when a referral is needed.3
The following citations are found in the American Dental Association's Principles of Ethics and Code of Professional Conduct:
2.B. CONSULTATION AND REFERRAL
Dentists shall be obliged to seek consultation, if possible, whenever the welfare of patients will be safeguarded or advanced by utilizing those who have special skills, knowledge, and experience. When patients visit or are referred to specialists or consulting dentists for consultation:
1. The specialists or consulting dentists upon completion of their care shall return the patient, unless the patient expressly reveals a different preference, to the referring dentist, or if none, to the dentist of record for future care.
2. The specialists shall be obligated when there is no referring dentist and upon a completion of their treatment to inform patients when there is a need for further dental care.
2.B.1. SECOND OPINIONS
A dentist who has a patient referred by a third party* for a "second opinion" regarding a diagnosis or treatment plan recommended by the patient's treating dentist should render the requested second opinion in accordance with this Code of Ethics. In the interest of the patient being afforded quality care, the dentists rendering the second opinion should not have a vested interest in the ensuing recommendation.
* A third party is any party to a dental prepayment contract that may collect premiums, assume financial risks, pay claims, and/or provide administrative services.
4.B. EMERGENCY SERVICE
Dentists shall be obliged to make reasonable arrangements for the emergency care of their patients of record. Dentists shall be obliged when consulted in an emergency by patients not of record to make reasonable arrangements for emergency care. If treatment is provided, the dentist, upon completion of such treatment, is obliged to return the patient to his or her regular dentist unless the patient expressly reveals a different preference.
SITUATIONS OR CONDITIONS NECESSITATING A REFERRAL
Patients may need to be referred for several reasons. Any one or any combination of the following situations or conditions may provide the dentist with appropriate rationale for referring a patient:
o level of training and experience of the dentist
o dentist's areas of interest
o extensiveness of the problem
o complexity of the treatment
o medical complications
o geographic proximity of specialists
o patient load
o availability of special equipment and instruments
o staff capabilities and training
o patient desires
o behavioral concerns
o developmentally disabled or handicapped patients
o desire to share responsibility for patient care
ELEMENTS OF DENTAL PATIENT REFERRALS
Interprofessional Communication Needs: General Dentists who initiate patient referrals should convey appropriate information to the specialists and determine on a case by case basis what information should be transferred from the following list:
o name, address of the patient
o appointment date and time
o reason for the referral
o general background information about the patient which may affect the referral
o medical and dental information, which may include
medical consultations and specific problems
previous contributory dental history
o projected treatment needs beyond the referral
o urgency of the situation, if an emergency
o information already given or told to patient
Additional information may be found below in the section titled, "Facilitating and Improving the Referral Process."
Communications from the General Dentist to the Patient: Many times the referral process is foreign to dental patients who have become accustomed to receiving their routine care at one specific office. It is essential that all parties involved understand what is necessary to complete the referral successfully. The following points should be considered:
o an assessment of the patient's ability to understand and follow instructions
o explanation of the problem to parent or guardian, if the patient is a minor
o indication of which area of dentistry or specialty is chosen and why
o a specific appointment made while the patient is in the general dentist's office
o if known and requested by the patient, information about the specialist's fee for the initial consultation or examination
o instructions that will assist the patient's introduction to the specialist; i.e., directions to the specialist's office
Communication from the Specialist to the Patient: The specialist should provide the following information to the patient:
o details of the referral services, fees and payment options
o proposed additional and alternative treatment
o details regarding the coordination of future treatment
o follow up appointment(s) if needed, and a return to the general dentist for completion of other treatments and/or maintenance
Communication Between the Specialist and the General Dentist: Communication between professionals is essential. Patients should receive clear, consistent information about their dental problems and treatment from all dental professionals. Mixed messages can confuse and frustrate patients and can undermine their confidence in the care provided.
It is the role of the general dentist to manage the overall dental health care of the patient. When appropriate, any care rendered by a specialist should be coordinated with that of a general dentist, with a clear understanding of the role of each in providing care to the patient.
The following steps can facilitate the communication process:
o initial report indicating the preliminary diagnosis by the specialist and anticipated treatment
o progress report, if treatment is extended over a considerable period of time
o final report which includes such things as adverse experiences and maintenance instructions plus recommendations for additional treatment
o any copies or duplicates of appropriate pre operative or post operative radiographs taken by the specialist.
o return of any original radiographs or forms provided by the referring dentist
FACILITATING AND IMPROVING THE REFERRAL PROCESS
Personal knowledge of the specialist provider will allow patient need to be met most appropriately. Dentists may wish to begin by looking for specialists with skills, knowledge, experience, and caring attitudes which complement their own. Inquiries about the specialists' training and experience, including their participation in continuing education and study clubs, may assist the dentist in determining where to refer particular cases. A visit to the specialist's office to observe treatment may be helpful.
The primary referring dentist and the specialist should also discuss cooperative working arrangements which would benefit patients being referred. Both practitioners should discuss the referral treatment period and the return of the patient to the primary dentist. This arrangement could be enhanced by an exchange of business cards, referral forms, and patient instructional materials. Availability of the specialist for emergency treatment as well as mid treatment referrals should be discussed. Radiographs should be promptly forwarded to the specialist and returned to the primary dentist.
Encouraging patient's questions about the referral and responding in lay terminology can ease some of the fears associated with unfamiliar treatments or providers. If language barriers exist, every effort should be made to ensure that the patient fully understands the reasons for the referral.
LEGAL AND ETHICAL ISSUES
Dentists should conduct themselves professionally and with dignity throughout the referral process. In addition to the therapeutic issues which form the basis for the referral, there are also legal and ethical considerations.
Legal Considerations: Dentists should recognize that separate and possibly conflicting legal interests may be involved during a referral. Particular attention should be directed toward patients or providers whose interests and requirements are detailed in contract form. When dentists or patients participate in such arrangements related to dental services, these arrangements should be reviewed carefully with respect to restrictions that may be placed on the dentist's ability to refer patients to other settings or providers for care.
Note: In some situations, a dentist could be held legally responsible for treatment performed by referral dentists. Therefore, dentists should independently assess the qualifications of participating referral dentists as it related to specific patient needs. The dentist is reminded that contract obligations do not alter the standard of care owed to all patients.
Ethical Considerations: Dentists should discuss their referral information with the patient in an appropriate manner. The ADA Principles of Ethics and Code of Professional Conduct Section 4.C. contains the following:
4.C. JUSTIFIABLE CRITICISM
Dentists shall be obliged to report to the appropriate reviewing agency as determined by the local component or constituent society instances of gross or continual faulty treatment by other dentists. Patients should be informed of their present oral health status without disparaging comment about prior services. Dentists issuing a public statement with respect to the profession shall have a reasonable basis to believe that the comments made are true.
4.C.1. MEANING OF “JUSTIFIABLE”
Patients are dependent on the expertise of dentists to know their oral health status. Therefore, when informing a patient of the status of his or her oral health, the dentist should exercise care that the comments made are truthful, informed, and justifiable. This may involve consultation with the previous treating dentist(s), in accordance with applicable law, to determine under what circumstances and conditions the treatment was performed. A difference of opinion as to preferred treatment should not be communicated to the patient in a manner which would unjustly imply mistreatment. There will necessarily be cases where it will be difficult to determine whether the comments made are justifiable. Therefore, this section is phrased to address the discretion of dentists and advises against unknowing or unjustifiable disparaging statements against another dentist. However, it should be noted that, where comments are made which are not supportable and therefore unjustified, such comments can be the basis for the institution of a disciplinary proceeding against the dentist making such statements.
Adopted by the AGD House of Delegates, 7/90
Editorially Revised by the AGD Dental Practice Council, 10/06
Universal Access to Health Care Position Paper
The Academy of General Dentistry recognizes that resolving the issue of access to health care is becoming increasingly urgent. This national problem affects Academy members on a variety of levels: As health care providers, small business owners, self employed persons, and as members of a national organization taking a part in a national debate. This position paper has been drafted from the perspective of the dentist as an employer and small business owner seeking to influence public policy. It recognizes that for fiscal reasons, dentistry is not likely to be included in a universal health program or other broad based efforts to provide care to the uninsured. It should be noted that this document represents the Academy's current position, which may change as the approaches to and consequences of health care reform become more apparent.