Making the Case

"Evidence-based care," experiencing growing use in medicine but still in its infancy relative to dental care, is gaining notice.

Dental education, organized dentistry and the insurance industry are taking closer looks at a system that challenges long-accepted thinking about the way dental care is provided.

With evidence-based care, not all patients are equal. Some, at higher risk for dental disease, are treated more aggressively than patients at low risk, who receive more conservative and preventative treatment. In theory, evidence-based care would help most patients to have fewer cavities and less periodontal disease, and costs to both dentists and insurers would decrease.

Dentistry has made slow, careful steps toward evidence-based care over the course of the last several years. In California, Delta Dental began investigating the concept in 1996 when it undertook a study at the University of California, San Francisco, School of Dentistry to demonstrate whether its use could lower costs and improve the oral health of patients. One of the principal researchers was Steven J. Silverstein, DMD, a UCSF professor of dental public health and hygiene for 28 years.

"We wanted to look at the evidence, and determine whether we could characterize people by their risk," Silverstein says. "We wanted to know if those with low to moderate risk could have a dental benefit that was cheaper and that emphasized maintenance and prevention, while those at higher risk might have a benefit at a different level."

He says that people at lower risk may not need all the restoration and replacement, once a hallmark of dentistry.

"There's still no scientific evidence that low-risk people need to visit a dentist once a year, or have their teeth cleaned twice a year," Silverstein says.

With the study results in hand, R. Steven Bull, DDS, senior vice president for Delta Dental of California, Public and Professional Services, sees data that indicates evidence-based care could work.

"But we found there's no consensus in the industry, among insurers, organized dentistry and academics, as to what is the new standard of care," he says. "We're talking about a lot of dramatic changes in dentistry, but we haven't seen this addressed by any of these parties."

Charles J. Goodacre, DDS, dean of the Loma Linda University School of Dentistry, agrees with Bull, and says he believes dental education has fallen behind in embracing evidence-based care.

"But we're beginning to catch up rapidly in the area of doing things and training people on the basis of evidence," he says. "Today's graduates are getting more information, so we're starting to turn out graduates who increasingly will use evidence in making diagnosis and treatment plans in the future. I encourage the profession to go in this direction. It's absolutely the future of training."

Roger K. Rempfer, DMD, chairman of CDA's Council on Dental Care, says that he has a particular interest in the issue.

"I'm interested in any entity that may prove it can offer enhanced quality of care and increased availability and affordability of care," he says.

One West Coast dental insurer is beginning to make inroads on implementing evidence-based care. Max Anderson, DDS, dental director at Washington Dental Service, a Delta Dental Plan Association member, says dentistry must change the way it has operated for many decades in order to embrace the new way of thinking.

"When insurance companies wrote their first programs in the '50s, caries was pandemic," Anderson says. "We had a payment system and dental industry designed to repair disease. Now we have through available science the ability to prevent the vast majority of disease."

Anderson says that since we can prevent most dental disease in many people who are not at risk, he won't have as much repair work to do.

"So I will have to become a better diagnostician, and a good risk prevention specialist," he says.

Anderson says his organization addressed a possible decline in income under this scenario by determining how to change the payment system to reward dentists for doing the right thing.

"We redirected resources into those areas where we can apply appropriate science, and to (make than an economic advantage) for the dentist and the patient," he says.

Twice-yearly fluoridated varnishes are included as a benefit for patients who are at risk for caries, for example, Anderson says.

As dental schools begin to implement an evidence-based care approach into their curriculums, ans as the dental insurance industry gets on board to help propel the new standard of care, organized dentistry is cautiosly optimistic.

Change has its risks, yet so does standing still, Rempfer said. Will the new be better than the old? Will it be a better standard, or one that looks good on paper but is yet more disjointed? Only time with tell.

Take Three Steps -- That's the Plan
By Marios P. Gregoriou

Many people work to accumulate assets with a goal of leaving a solid financial legacy to their heirs. But building an estate is just one part of the equation. Planning its distribution, even if the estate is moderate, is as important.

A carefully crafted estate plan ensures that assets reach the people chosen to receive them, in a chosen manner. A well-prepared estate plan ensures that property is distributed to a person's spouse, children and chosen others.

Equally important, such a plan may reduce or eliminate estate taxes.

The first step is assessing the value of one's estate. Current federal law allows an unlimited amount to be left to a spouse free of federal estate tax. Applying the unified federal tax credit of $211,300 (for 1999) against estate taxes allows one to leave as much as $650,000 tax-free to beneficiaries other than a spouse.

Any amount over $650,000 is subject to a federal estate tax starting at 37 percent and rising as high as 55 percent, depending on the estate size. An estate can reach the $650,000 threshold quickly with the combination of a home's market value, investments, personal property, owned businesses, retirement benefits, and face value of life insurance policies.

A second step is review of one's family situation and objectives, and consideration of: whether the spouse is a capable money manager, or if funds should be left in a trust (with determination of a trustee); where property should go after the spouse's death; whether all children are to be treated equally, or if any have special medical or educational needs; whether there will be other beneficiaries, such as a university or charity; if one's business includes a "buy-sell" agreement to ease transfer of the company stock, and if sufficient cash is available to fund the agreement.

The primary concern of a person with a family probably is to ensure that the estate is passed on to spouse and children in the amounts intended. An unmarried person might want to designate beneficiaries and provide for management of financial affairs in the event of becoming disabled.

The third step is to consult a financial adviser and tax professional, as well as an attorney who can draft an appropriate will and appropriate trust agreements.

Depending on the value of the estate, an approximately drafted will can help reduce, defer or even eliminate estate tax on one's property. For example, a will that leaves all assets to a spouse guarantees estate taxes won't be levied because of the "unlimited marital deduction." However, if a spouse does not remarry and dies with a combined estate of more than $650,000, the heirs may face estate taxes.

One way to lower heirs' future tax bite is to set up a "bypass" trust. Trusts are legal devices that hold property for the benefit of named beneficiaries. Via a trust agreement (established either outside or within a will), a manager is named for the assets placed in the trust with instructions about how distributions are to be made.

Since money in a bypass trust does not go directly to the spouse, it is not considered part of his or her estate, but he or she can benefit from having the income and a limited amount of principal from the trust. Heirs receive the balance of the principal upon the spouse's death.

Marios Gregoriou is associate vice president and financial adviser with Morgan Stanley Dean Witter in Sacramento. He can be reached at (800) 755-8041. Information in this article was obtained from sources considered to be reliable. This article does not constitute investment or tax advice. Consult an investment adviser or tax attorney before making investment decisions.

Flossed in Space

What if a patient suddenly had a toothache -- in space?

As common wisdom holds, prevention is the key, especially for astronauts. Regular preventive care has virtually eradicated dental problems for astronauts during space missions.

Dr. Jerold W. Miller, president of the Philadelphia County Dental Society, shared with the opening session of the 68th annual Liberty Dental Conference information from NASA's first report on dental problems in space. The report, from Dr. Michael Hadatt, head of NASA Dental Clinic in Houston, indicates that astronauts are carefully examined prior to space missions.

"Astronauts are also instructed to brush and floss every day -- even when in a weightless condition -- during their space flights," according to Hadatt.

NASA's objective is to avoid dental emergencies during missions. However, should an emergency occur, a flight crew member -- generally a physician -- is prepared with medication and equipment to treat most dental situations.

NASA's Dental Department and Flight Medicine Department conduct studies in bone mass changes during and after space missions.

"Only slight changes in bone mass have been noted," Hadatt reports, "but nothing intense. In addition, follow-up examinations are regularly scheduled after the missions to determine if further treatment is necessary."

The last major dental emergency occurred two years ago on MIR, the Russian space station, when an astronaut had to return to Earth because his condition proved too serious for in-flight treatment.

Crunching Practice Numbers

The ADA Survey Center has released two new reports on dental profession statistics.

"Income from the Private practice of Dentistry" is the first in a series of five reports from the 1997 Survey of Dental Practice. The report provides national and regional income figures for general practitioners and specialists as a group. Income is further broken down by dentist age, years in practice and hours worked. Gross billings are included.

The "1997 Survey of Dental Graduates" provides information on 1996 dental school graduates one year after graduation and includes comparison with previous graduating classes. The survey, mandated by the ADA House of Delegates, is part of Distribution of Dentists, a census-type survey of all known dentists. Information collected from the survey includes primary and secondary occupation; state(s) and types(s) of licensure; self-reported area of practice; research or administration; gender; race; ethnicity; and date of birth.

"Income from the Private Practice of Dentistry" (catalog No. 5197) is available to members for $35 shipping and handling. The price to members for the "1997 Survey of Dental Graduates" report (catalog No. 5SD7) is $15 plus shipping and handling. Order directly from the ADA Survey Center by calling the members' toll-free number, extension 2568.

Doing the Work Where It's Needed Most

English researchers have determined that water fluoridation is actually better at reducing tooth decay in areas of socio-economic deprivation.

Researchers at the North West Dental Public Health Resource Centre in Wesham, England, conducted a study of 6,638 children age 12 in the north of England who had a dental examination. Half were in Newcastle, where the water has been fluoridated for more than 20 years, and the other half were in nonfluoridated Liverpool.

The two areas were further divided into 30 areas defined by social deprivation. As expected, in both Newcastle and Liverpool, the amount and severity of tooth decay increased with socio-economic deprivation. However, the study also found that the improvement in levels of tooth decay in deprived areas with water fluoridation at one part per million was over and above that which would be expected simply because there was more decay.

In England as a whole, there was a 37 percent reduction in the amount of tooth decay in 12-year-olds in fluoridated areas. However, researchers found that in very deprived areas the reduction was more than 50 percent. More than half of all potential tooth decay was prevented.

Dr. Colwyn Jones, the research director of the Northwest Dental Public Health Resource Centre, says, "I estimate that there are 50,000 rotten teeth in 12-year-old children in the northwest of England. With water fluoridation, the number of rotten teeth would be almost halved."

Forget the VCR, Will My ATM Work?

With everyone scrambling to get ready for the Y2K computer glitch, it's easy to get caught up in the excitement -- especially when it comes to money. But what's real and what's just hype?

The latest information about being protected against possible financial hitches can be found in "The Year 2000, Your Bank and You" from the Federal Deposit Insurance Corp.

A question-and-answer section provides information about who is monitoring banks' Y2K efforts and how people can tell if their bank has taken steps to prepare. An eight-point checklist offers specific tips on how a person can be protected. To order a free copy, call (888) 878-3256 and ask for item 613F; or send name and address to Consumer Information Center, Dept. 613F, Pueblo, CO 81009.

Normal banking routines should not be disrupted, but all bank records from the last six months of 1999 and the first few months of 2000 should be kept. Comparison of personal bank records and bank statements also is encouraged.

Flu Vaccines Helps Keep Health Professionals on the Job

Annual flu shots are effective in preventing infection and onset of respiratory illness and may reduce work absences, according to an article in the March 10 issue of the Journal of the American Medical Association.

James A. Wilde, MD, formerly of Case Western Reserve University School of Medicine in Cleveland, and colleagues studied 264 young health care professionals without chronic medical problems at two teaching hospitals in Baltimore to determine the effectiveness of an influenza vaccine.

The researchers reported that the flu vaccine was 88 percent effective in preventing influenza type A infection and 89 percent effective in preventing influenza type B infection, compared to the placebo group. The researchers also report that the flu vaccine reduced the number of days absent from work by 53 percent and reduced the number of days of respiratory illness accompanied by fever by 29 percent.

Gum Disease Linked to Respiratory Problems

Scientists have found that when a person inhales some of the bacteria that grow in the mouth and throat, they enter the lungs and can cause respiratory diseases, including pneumonia, reports the American Academy of Periodontology.

This is especially true in people who have gum disease. In particular, those with chronic obstructive pulmonary disease appear to be more vulnerable to this route of infection. These patients often have poor protective systems, so it's difficult to throw off the bacteria.

Studies are now in progress to learn to what extent oral hygiene, such as careful flossing, may prevent this problem, according to Respiratory Health Monitor, newsletter of Data Centrum Communications, Winter 1999.

Smokers Don't See Increased Risk

Most smokers do not perceive themselves at increased risk of experiencing heart disease or developing cancer, according to an article in the March 17 issue of the Journal of the American Medical Association.

John Z. Ayanian, MD, MPP, of Brigham and Women's Hospital, and Paul D. Cleary, PhD, of Harvard Medical School, both in Boston, conducted a survey to assess smokers' perceptions of their risks of heart disease and cancer. The survey included 3,031 adults aged 25 to 74 years, including 737 current smokers (24.3 percent).

The authors found that only 29 percent of current smokers in the study believed they have a higher-than-average risk of myocardial infarction, while only 40 percent believed they have a higher-than-average risk of cancer.

The researchers also found that only 39 percent of heavy smokers (greater than 40 cigarettes per day) acknowledged the increased risk of myocardial infarction and 49 percent acknowledged the increased risk of cancer. Among smokers who had hypertension or a family history of MI, fewer than half perceived their risk of myocardial infarction as higher than average (48 percent and 39 percent, respectively).

Honors

Albert O.J. Landucci, DDS, of San Mateo, Calif., has been elected president of the California Association of Orthodontists.

Upcoming Meetings

1999

Sept. 1-4 Surfaces in Biomaterials '99, Scottsdale, Ariz. (612) 512-9103
Sept. 2-4 Academy of Surgical Research 15th Annual Meeting, Scottsdale, Ariz. (612) 545-1919
Sept. 16-18 CDA Scientific Session, San Francisco (916) 443-3382, Ext. 4470
Sept. 17-18 Society for Advanced Dentistry Annual Meeting, New Orleans (317) 290-2613
Sept. 25-29 American Academy of Periodontology 85th Annual Meeting, San Antonio, Texas, www.perio.org

2000

April 6-8 Dentistry 2000 -- British Dental Association Annual Conference and British Dental Trade Association Dental Showcase Exhibition, Birmingham, England 01934 844408
Sept. 17-20 American Academy of Periodontology 86th Annual Meeting, Honolulu, www.perio.org
To have a meeting included on this list, please send the information to Upcoming Meetings, CDA Journal, P.O. Box 13749, Sacramento, CA 95853 or fax the information to (916) 443-2943.