NWD: We began Part One of this discussion with the “brass tacks” tools of clinical practice: materials. The tools required when we are not chairside are considerably different, and yet they too are what let us do what we do when they work right. That would make the basic question “What’s working … and what isn’t?”
Dr. Larson:** I think the operative word here is going to be “different”. Political and licensure issues, for example, are definitely different today. Access, now called “barriers to care”, was not even discussed in 1970. Today it is a critical discussion. Sadly, not enough has been done to develop community-based prevention efforts to have made a difference. A significant number of our population still suffers from caries infection.
Licensure remains a hot topic now as it was in 1970, when all the states had individual clinical examinations and it was commonly known that some used that device to prevent entry of new dentists. Today there are regional licensing examinations (CRDTS, NERB), and many states accept the results of any of the regional clinical licensing examinations. This has improved the portability of talent around the nation. Sadly, we still rely heavily on a patient-based examination that at times is unethical, does not identify unprepared, incompetent applicants accurately, and whose cost has become prohibitive. These examinations mostly test technical skills, and to a small degree clinical judgment. If you have looked through the Board of Dentistry website (an excellent way to communicate broadly to all licensees), the vast majority of disciplinary actions are not for technical issues, but most often for poor judgment. In my opinion, a better approach is what Minnesota has done by accepting the Canadian Board results, and I extend my kudos to the Minnesota Board of Dentistry for their bold action. Regrettably, other states have not followed their lead.
NWD: How are legislative and political activism a part of this process?
Dr. Larson: The interaction between organized dentistry and the legislature was not warm and inviting in 1970, and it has become even worse over the ensuing years. Recent efforts by the MDA I hope will bear fruit. I have always believed we, the dentists of this state, are in the best position to educate our legislators about the science of dentistry, particularly about the cost effectiveness of prevention.
NWD: The impact of money, usually with a capital “M”, cannot be underestimated. From distractions to game-changers, what are some of the issues now?
Dr. Larson: A dentist creating a treatment plan today has to include both the practicalities of what the patient can, and is willing, to do, and the science of what can be done. The consternation about what we can do versus what we can afford to pay for is not going to go away, so we must address it.
Dental insurance, a rarity in 1970, is mostly ubiquitous for about 60% of the population, and has no doubt improved overall dental health as a result. Restrictive insurance organizations, however, have tried to dictate treatment. Yet some of the insurance companies have recognized the long-term benefit of prevention. The concept of Delta Dental, originally fostered by the Minnesota Dental Association, has grown into a big business.
New dental business models have sprung up and grown so that large group practices with multiple facilities, rare in 1970, are now a valuable part of dental practice in Minnesota. Today we have HealthPartners, Park Dental, and Metro Dentalcare.
The debt level of students in 1970 was generally small. Now our recent graduates owe $200,000 or more, restricting their opportunities to choose the type of practices in which they eventually wish to work. Most new dentists work “for someone else”, whether in small and large practices, public health clinics, the armed forces, residencies, or GPRs. It may take more than ten years for them to establish themselves in the profession.
NWD: You have trained more than 4,000 dentists over a 40-year career. What are today’s students like, and what are they facing?
Dr. Larson: Today’s students are very different from those of the past. In 1970 there were no women in the dental graduating class. Today’s number is usually 40-50%.
The quality of the incoming students is different as well. They all have four-year or more degrees, whereas in 1970 only about half of them did. Back then some came with two years or three years of college. DAT results are significantly higher for the entering classes than they were in 1970.
The students’ scientific preparation is more thorough. For example, they have to have taken biochemistry prior to entering dental school. Their outside curricular interests are more varied, and they must demonstrate leadership skills.
NWD: And patients?
Dr. Larson: Today’s patient base is significantly more diverse because of immigration and the addition of more rural clinics and inner city clinics in our outreach clinical training locations around the state.
As for demographics, today’s patients fall into one of four generations, all presenting with different needs.
The oldest generation has many, and large, restorations, and many crowns. Some need complete or partial removable prosthetics because of many lost teeth.
Members of the next youngest group have most of their teeth, but with many crowns and large restorations, and they have experienced a lot of broken teeth.
Then comes the generation that has reaped the full benefit of fluoride in the water. They have fewer restorations, which are usually very small, no missing teeth, and few crowns.
Then we have the soda pop generation. They have many restorations, although these are usually smaller. A few have lost teeth. Members of this generation who have been exposed to methamphetamines present in the dental office with mouths that are a disaster.
For the newest generation, the outlook, and the outcome, will depend upon how well we put prevention to use more broadly in communities. We have begun seeing them sooner as patients, even as young as one or two years of age. On hopeful sign is that at least some school districts have removed most of the soda pop from their schools. As for what they can expect, I would say there will be a greater emphasis on lesion-specific cavity designs and smaller restorations (no more extension for prevention). I would expect to see fewer tooth fractures, fewer crowns, and more indirect partial restorations of porcelain and possibly gold. This generation almost certainly will use only implants and no bridges for missing teeth. Without proper public policy changes, a significant quantity of this generation will grow up with the same outcomes as the most previous “soda pop generation”.
NWD: What are the questions that remain, that continue?
Dr. Larson: We will need to keep identifying who or what is initiating, motivating, even demanding, and thus creating, change. It can be driven by science, our patients, the practitioners, the dental industry. We must not let ourselves be “driven” into a reactive position. We need to attend to what is keeping brows furrowed, what is clouding the crystal ball, in effect, by listening to our patients, our colleagues, and our new dentists and dental students. What are they asking for?
As well, we need to listen to ourselves. After handling all this information and questioning of the future, an essential element remains finding what makes us happy, no matter where we are in our professional journeys.
Our colleague who began this discussion with her story about the things she missed in practice has, fittingly, given us our closing thought. As everyone does at one time or another, she had a day when she asked, “Do you think I have maybe been in this business too long?” And her answer was, “No way, my friends — it’s just getting good!”
In 2010, the School of Dentistry received a Gies Award for Vision from the American Dental Education Association for its role in advancing new licensure standards in Minnesota. That refers to the 2009 decision by the Minnesota Board of Dentistry to accept the National Dental Examining Board of Canada’s non-patient-based licensure exam for U of M graduates seeking initial licensure to practice in Minnesota. They did so, in part, in response to a request from the School of Dentistry when it questioned the ethics of a live subject examination.
The School opened its doors and invited Board representatives to review the procedures it had in place to assure that a quality group of students is admitted, an up-to-date and validated education is offered, and that systems are in place to assess competency and to promote and graduate students prepared to practice dentistry. Board members had insights into the inner workings of the dental school and the confidence that candidates applying for licensure are clinically competent, having been critically evaluated on an ongoing basis throughout their four years of dental education.
The Board of Dentistry decision to accept the two-part Canadian exam as a condition for initial licensure to practice dentistry in Minnesota is an arrangement exclusive to University of Minnesota graduates. The decision positions Minnesota as the first state in the U.S. to move beyond reliance on examinations that require applicants for licensure to perform procedures on live patients.
*“The Top Ten List of Things We Don’t Do Anymore/The Best of Now”, Northwest Dentistry, May-June 2013, pages 14-18.
**Interview conducted with Thomas D. Larson, D.D.S., M.S.D., Associate Professor, Division of Operative Dentistry, Department of Restorative Sciences, University of Minnesota School of Dentistry. Dr. Larson’s email is firstname.lastname@example.org