NFECTION
CONTROL
HOW INFECTION CONTROL PROCEDURES ARE AFFECTING DENTAL PRACTICE TODAY
KENT D. NASH, PH.D.
ABSTRACT
T h e p a s t c o u p le o f y e a r s h a v e g iv e n U .S. d e n t is t s a lo t to th in k a b o u t. O SH A r e g u la tio n s , a d e c lin in g eco n o m y , lin g e r in g con cerns about flu o r id a tio n , d e n ta l a m a lg a m a n d s a fe ty in h e a lth c a r e s e tt in g s h a v e c a p tu r e d th e a tte n t io n o f d e n t is ts e v e r y w h e r e .
Q ractices and procedures aim ed at assuring reasonable dental office safety of patients, dentists and dental team m em bers have been adopted generally in dental practices across the U nited States. The use of gloves, m asks, gowns and protective eyewear has become standard in m any dental practices ju st w ithin the p a st five years. Through surveys of dentists, th e ADA since 1986 has m onitored the adoption and use of infection control procedures. The first such survey, con ducted in late ’86, was distributed to a national random sample of about 5,700 dentists. Growing attention to the AIDS virus from the news media, governm ent regulatory agencies and dentists them selves spurred a repeat of the survey in early 1988. A nother random sample of about 5,700 dentists received a question naire from the ADA th a t year, and a comparison of results
from ’86 and ’88 appeared in JADA in May 1989. In addition to those special surveys, dentistry’s adherence to recommended infection control procedures also was m onitored through the Association’s “Q uarterly Survey of D ental Practice.” In the fourth qu arters of both 1988 and 1990, this survey included questions about compliance w ith infection control recom m endations. The survey, w ith about 1,500 respondents each quarter, is p a rt of an ongoing Association activity aim ed a t providing dentistry w ith tim e series and trend inform ation on the details of dental practice. By including questions on compliance to infection control recom mendations, the ADA used its quarterly survey to assess any economic im pact those recom m endations m ight be having on dental practice. The quarterly survey was used again during the fourth qu arter of 1991 to exam ine JADA, Vol. 123, March 1992
67
INFECTION
CONTROL
compliance w ith recommended b a rrier techniques, but results of th a t survey were not available a t press time. Beyond th e special survey and q u arterly reports, the Association’s “1991 Special Version Survey of Dental Practice” also included questions about compliance w ith infection control procedures. Federal recom m endations and regulations on dental practice infection control procedures have raised m any issues, only a few of which can be dealt w ith here. The key questions to be addressed in th is report are w hether dentistry has complied w ith recom mended infection control procedures; the econo mic im pact compliance is having on dental practice; and how dentists perceive the larger issue of tre a tin g patients infected w ith the AIDS virus.
TABLE 1
INTENSITY OF USING BARRIER T E C H IE S I Ï TEAM INVOLVEMENT FOR AEE PATIENTS, I99I T E C H N IQ U E
D E N T IS T %
D E N T IS T A N D A S S IS T A N T /o
68
JADA, Vol. 123, March 1992
AND H Y G IE N IS T
% G LOVES
9 1 .8
76.1
8 7 .5
G LO VES, MASK
64.7
5 0 .0
6 0 .6
G LO VES, MASK, GOW N
6 1 .6
4 4 .2
53.3
GLOVES, MASK, GOW N, EYEW EAR
4 2 .5
2 7 .7
32.0
Source: ADA, 1991 Special version survey of dental practice.
about 12 percent said they wore gowns for all patients. D ental assistan ts seem to have m irrored the dentist’s p a tte rn
in adopting barrier techniques. I t was reported in 1986 th a t fewer th a n one in four assist ants used gloves, m asks or
TECH
H A S D E N T IS T R Y C O M P L IE D ?
Are dentists employing recom m ended b a rrier techniques? The evidence reported to the ADA since 1986 indicates th a t dentists and dental team m em bers are adopting standard b a rrier techniques a t a rapid rate. The use of gloves, m asks, and gowns by dentists on all p atients has increased th rough out the practice of dentistry and over tim e. Eyewear (both protective and corrective) has been used by about 80 percent of dentists since 1986 and has rem ained relatively steady. In 1986, slightly more th an 20 percent of dentists reported using gloves on all p atients and about the sam e percentage indicated using a m ask. Only
DE/MJt\ S T A S S IS T A N T
A L L P A T IE N T S 100
1986 □ 1988 91 1991
90 80 70
?—?1—
£ 60 IU
0 50 O C IU
a. 4 0 30
20 10
G LO V E S
MASK
GOWN
TECHNIQUE Source: ADA, 1986, 1988,1991 Special version survey ADA, Quarterly survey
EYEW EAR
INFECTION
TABLE 2
AVERAGE FEES BY PRACTITIONERS. BY HIGH VS. LOW BSE BF INFECT! CONTROL, 1990 PROCEDURE
LO W USER
H IG H USER
FEE D IF F E R E N C E
S
°/o
S
ORAL E X A M
17.74
15.73
12.8
R A D IO G R A P H
2 1 .7 2
2 0.25
7.3
P R O P H Y L A X IS
3 7 .4 9
3 3 .4 8
12.0
AM ALG AM
4 0 .97
3 7 .2 9
9.9
GOLD CROW N
4 6 2 .6 0
4 2 8 .4 0
8.0
UPPER
6 1 6 .7 0
5 48 .5 0
12.4
E X T R A C T IO N
5 2 .4 5
4 5 .44
15.4
ROOT CANAL
3 7 5 .5 0
3 4 5 .1 0
8.8
8 1 .8 7
7 6.74
6.7
DENTURE
P E R IO S C A L IN G
Source: ADA, Q uarterly Survey of D ental Practice.
th a n dentists. B ut th eir use of m asks and gowns reflected the relatively low usage of these
gowns for all dental patients. H ygienists historically have used gloves a t a higher rate
HYGIENISTS: BARRIER TECHNIQUES
A L L P A T IE N T S
io o
1986
LI 1988
B 1991
90 80
¿atm
70 2
60
111 0
E IU
50
Q . 40 30
20 10 O GLOVES
MASK
GOWN
TECHNIQUE Source: ADA, 1986, 1988, 1991 Special version survey ADA, Quarterly survey
EYEWEAR
C
O
N
T
b a rrier item s by dentists and assistants. Five years later, the picture had changed dram atically. By 1991, more th an 60 percent of dentists indicated using gloves, m asks, gowns or eyewear for all patients. Use of gloves has risen to more th a n 90 percent among dentists, hygienists and dental assistants. M ask utilization has climbed to more th a n 60 percent of dentists and assistan ts, and more th an 75 percent of hygienists. Use of gowns took a significant jum p in 1991 when 64 percent of dentists, more th an 75 percent of hygienists and about 60 percent of assistan ts reported using them . To delve deeper into the subject of compliance, the 1991 survey exam ined three key indicators: *■ the extent to which dentists use all techniques on all patients; ■* th e extent to which dentists and assistan ts use all techniques on all patients; and "■ th e extent to which dentists, assistan ts and hygienists use all techniques on all p atients in practices th a t employ a hygienist. The overall picture of how dentists are using b arrier techniques changes w hen one technique is m atched in combi nation w ith another (Table 1). For example, alm ost 92 percent of dentists indicated they use gloves on all patients, b ut 65 percent use both gloves and m ask. Sixty-one percent use gloves, m ask and gown, and ju st 43 percent use gloves, m ask, gowns and eyewear. Going a t th is another way, fully 91 percent of dentists, when not m easured w ith staff, use gloves for all patients. W hen glove use is m easured for JADA, Vol. 123, March 1992
69
R
O
L .
TABLE 3
practice dentist. Average gross billings PERCENT for 76% procedures rendered 69% have 53% advanced about 6.7 percent in 32% 1990 15% rising about 8.7 percent 11% each year since 1987. 11% Average an nual gross billings have exceeded the inflation rate since 1983. In 1990, the average net income from practice of dentistry reached $96,500. And since ’83, net earnings have advanced 6.7 percent per year compared to an annual inflation ra te of 4.0 percent. Total average operating
THREE MOST IMPORTANT ISSUES FACING DENTISTRY TODAY G E N E R A L IS S U E THE GENERAL ECO NO M Y O S H A R E G U L A T IO N S A ID S /H IV IN F E C T IO N C H A N G IN G P A T T E R N S O F D IS E A S E M A L P R A C T IC E IN S U R A N C E F L U O R ID A T IO N M ER C U R Y AM ALG AM
dentists and assistan ts together, compliance is 76 percent. For dentist, a ssista n t and hygienists combined, glove usage is 88 percent. About 28 percent indicated the dentist and assistan ts all use gloves, m ask, gowns and eyewear while tre a tin g all patients. In those practices employing a hygienist, 32 percent indicated the dentist, a ssista n t and hygienists all w ear gloves, m asks, gowns and eyewear to tre a t all patients. As a rule, practices employ ing hygienists show a generally higher proportion of all dental team m em bers using all the b arrier techniques for all patients.
expenses for dental offices rose a t a rate of 8.6 percent each year from 1987 through 1989, b ut jum ped about 11 percent in 1990. Salaries of non-dentist staff, dental supplies expenses and laboratory charges together account for about 56 percent of all operating expenses. Over the p ast three years, supplies expenses alone have increased 6 percent.after Laboratory charges have risen 7.5 percent and staff salaries are up 13.7 percent. Clearly, staff salaries are signif icantly boosting overhead expenses, reflecting the current shortage of office personnel. In 1990, dental fees increased an average of 6.7 percent against an inflation ra te of 5.4 percent. B ut the long-term inflation in dental fees (the p ast 20 years) has been 7.1 percent a year, lagging ju st behind an overall inflation rate of 7.2 percent. Rising practice costs p ut pressure on dentists to in
A L L P A T IE N T S
T H E E C O N O M IC IM P A C T
Guidelines for using barrier techniques are intended to boost the overall safety of patients, dentists and dental team m em bers. Their adoption affects tre a tm e n t procedures rendered in the dental office, practice costs and fees charged to patients. Between 1985 and 1990, overall economic conditions have improved for the private 70
JADA, Vol. 123, March 1992
TECHNIQUE Source: ADA, 1986, 1988, 1991 Special version survey ADA, Quarterly survey
INFECTION: CONTROL
crease fees, but inflation u n d er m ines the value of these fee increases. Com plicating dentistry’s economic scenario over the past few years has been growing concern w ith infection control procedures. These procedures, not surprisingly, are affecting practice costs and dental fees. E arly on, practitioners probably absorbed the costs for barrier techniques by adjusting the rate a t which th e techniques were adopted, by lowered n et earn ings or by offsetting ad ju st m ents in other expenses. More recently, there have been signs th a t dentists are beginning to pass on these added costs to p atien ts in the form of higher fees. The use of gloves, gowns, m asks, and eyewear all directly affect the dental office supplies budget regardless of w hether the dentists use the procedures on some or all the patients. Costs of dental supplies today account for roughly 10 percent to 12 percent of a practice’s to tal average expense. Over the p ast seven years, the supplies expense per patien t visit has increased from $6 per visit to about $12.50 a visit, a rise of about 108 percent w ithin the period. To compensate, gross billings per visit have increased 10.5 percent each year since 1986. O ther rising costs include overall supplies expense (11.1 percent a year); assistan t salaries (6.5 percent a year); and hygienist salaries (8.9 percent a year). Those adopting recom mend ed b a rrier techniques incur higher supply expenses per p atien t visit th an those who have not complied w ith the procedures or who use them only w ith some patients.
SUPPLY EXPENSE AND BARRIER TECHNIQUE
G Ps, 4TH Q U A R TE R , 1088, 1990 18
16
S i 6.35
$15.90
14
12 10 8 6 4
2 .
O 19 9 0
1988
YEAR USE OF BARRIERS
S o u rce:Q u arterly S urvey of D en tal P ractice
U S ER S NO N-USERS
U sing the 1991 survey data, general dentists were divided into: heavy users—dentist and a ssistan ts use gloves and m asks for all patients and w ear gloves, m asks and gowns for some patients; ■■ low users—either do not use b a rrier techniques or use gloves and m asks only for some patients. About 39 percent of general dentists and 38 percent of specialists are heavy users. N early 36 percent of solo dentists and 49 percent of dentists in non-solo practices are high users. High users are 44 years old on average. In 1988, the average supplies expense for heavy users was about $16.40 per patient visit. Low users spent about $10.85 per patien t for infection control procedures. As more dentists
w ent from low u sers to heavy users of b arrier techniques, this sharp difference declined. By 1990, average supplies expense per p atien t visit was $15.90 for heavy users vs. $11.90 for lower utilizer. I t’s also likely th a t this difference was fueled, in part, by a shortage of surgical gloves experienced in th e late 1980s, which had the effect of driving up costs. The use of b arrier techniques has also boosted the tim e den tists devote to each p atien t— donning gloves, m asks, gowns and protective eyewear, and properly disposing of the item s after use. As a result, heavy users of b arrier techniques see roughly 410 fewer patients each year and spend about six m in utes longer w ith each patient th an low users. These cost and tim e factors have lead to higher fees for dentists who are heavy JADA, Vol. 123, March 1992
71
« N F E C T ,C E S S E S !
............... '
^
users of b ar rie r tech niques (Table 2). The average fee charged is greater among the general practitioners who are greater utilizers of the infection control pro cedures. The percentage difference ranges from a low of about 7 per cent for radiograph fees to a high of 15 percent for extrac tions. The average per cent differ ence in fees for the proce dures shown in Table 2 is about 10 percent. The compliance w ith infection control procedures affects dental practice costs, p attern s of practice am ong dentists, and procedure fees charged by dentists. D entists who are the heavier utilizer of the recom m ended b arrier techniques are experiencing about one-third higher supplies expenses, spending more tim e per patien t visit, treatin g fewer patien t visits per year, and charging about 10 percent higher fees. W H A T C O N C ER N S YOU?
The p ast couple of years have 72
JADA, Vol. 123, March 1992
given U.S. dentists a lot to th in k about. OSHA regulations, a declining economy, lingering concerns about fluoridation, dental am algam and safety in health care settings have captured th e atten tio n of dentists everywhere. The ADA’s 1991 “Special Version Survey of Dental Practice” included a num ber of questions aim ed a t d entists’ attitud es and opinions on several m ajor issues (Table 3). The state of the economy was upperm ost in the m inds of three out of four dentists responding
to the survey. Close behind were OSHA regulations and HIV/AIDS infection dental am algam safety. Growing concerns w ith protec tion and safety m ean dentists and dental team m em bers are more likely to hear p atien t questions about barrier techniques. The special survey found th a t about 75 percent of the dentists had fielded patien t questions about the use of b a rrier techniques. About 70 percent also indicated th a t patien ts had discussed the techniques w ith th eir staff. Only one in five dentists said th eir p atients had n ’t asked about infection control procedures. New patients are less likely to inquire th an long-term patients. J u s t 2 percent of dentists said patients of record had asked about the d en tist being tested for HIV antibodies. On the other hand, th ree out of four dentists said they ask patients, in the course of gathering medical histories, about th eir
INFECTION
HE ISSUE WITH GREATEST IMPACT
CONTROL.
lesions norm ally associated w ith th e condition b u t did not inquire further. In addition, 22 percent have had a t least one p atien t they assum ed had AIDS or w as HIV positive only because of the p a tie n t’s appearance.
9 9 1
TH E YEARS AHEAD
GENERAL ECONOMY
OS H A REG S
H IV /A ID S
D IS E A S E P A TTE R N S
FLUORID A T IO N
D E N TA L AM ALGAM
ALL O TH ER
ISSUES Source: S pecial V ersion Survey, 1991
HIV/AIDS status. J u s t under a th ird of dentists responding said they had knowingly tre a te d a p atien t infected w ith HIV or AIDS. Most of these said they had learned the p atien t’s statu s m ainly through routine dental and medical inquiries, medical histories and other pre-treatm ent disclosures. Roughly 35 percent of
dentists said they learned of a p atien t’s HIV/AIDS condition by asking about it after noticing an oral lesion associated w ith the AIDS virus. M any dentists believed they had treated HIV/AIDS patients but had not asked the p atien t to confirm th eir suspicion. Tw enty percent of all den tists who believe they treated HIV/AIDS p atients found oral
The various factors described in th is paper have spurred dram atic changes in dental practice w ithin a very brief period. The ’90s will likely bring still greater change a t an everquickening pace. The new OSHA Bloodborne Pathogen S tandard, the longanticipated new guidelines from the C enters for Disease Control and growing professional and public concerns have and will continue to affect the practice of dentistry as reflected in rising costs and fees. The ADA, through its B ureau of Economic and Behavioral Research, will m onitor, analyze and report these developm ents as they occur in an effort to keep th e m em bership fully informed and prepared for the future. ■ T h is r e p o r t w a s p re p a r e d b y K e n t D . N a s h , P h .D ., d ire c to r o f th e A D A B u r e a u o f E co n o m ic a n d B e h a v io ra l R e se a rc h .
JADA, Vol. 123, March 1992
73
CONTROL
HOW INFECTION CONTROL PROCEDURES ARE AFFECTING DENTAL PRACTICE TODAY
KENT D. NASH, PH.D.
ABSTRACT
T h e p a s t c o u p le o f y e a r s h a v e g iv e n U .S. d e n t is t s a lo t to th in k a b o u t. O SH A r e g u la tio n s , a d e c lin in g eco n o m y , lin g e r in g con cerns about flu o r id a tio n , d e n ta l a m a lg a m a n d s a fe ty in h e a lth c a r e s e tt in g s h a v e c a p tu r e d th e a tte n t io n o f d e n t is ts e v e r y w h e r e .
Q ractices and procedures aim ed at assuring reasonable dental office safety of patients, dentists and dental team m em bers have been adopted generally in dental practices across the U nited States. The use of gloves, m asks, gowns and protective eyewear has become standard in m any dental practices ju st w ithin the p a st five years. Through surveys of dentists, th e ADA since 1986 has m onitored the adoption and use of infection control procedures. The first such survey, con ducted in late ’86, was distributed to a national random sample of about 5,700 dentists. Growing attention to the AIDS virus from the news media, governm ent regulatory agencies and dentists them selves spurred a repeat of the survey in early 1988. A nother random sample of about 5,700 dentists received a question naire from the ADA th a t year, and a comparison of results
from ’86 and ’88 appeared in JADA in May 1989. In addition to those special surveys, dentistry’s adherence to recommended infection control procedures also was m onitored through the Association’s “Q uarterly Survey of D ental Practice.” In the fourth qu arters of both 1988 and 1990, this survey included questions about compliance w ith infection control recom m endations. The survey, w ith about 1,500 respondents each quarter, is p a rt of an ongoing Association activity aim ed a t providing dentistry w ith tim e series and trend inform ation on the details of dental practice. By including questions on compliance to infection control recom mendations, the ADA used its quarterly survey to assess any economic im pact those recom m endations m ight be having on dental practice. The quarterly survey was used again during the fourth qu arter of 1991 to exam ine JADA, Vol. 123, March 1992
67
INFECTION
CONTROL
compliance w ith recommended b a rrier techniques, but results of th a t survey were not available a t press time. Beyond th e special survey and q u arterly reports, the Association’s “1991 Special Version Survey of Dental Practice” also included questions about compliance w ith infection control procedures. Federal recom m endations and regulations on dental practice infection control procedures have raised m any issues, only a few of which can be dealt w ith here. The key questions to be addressed in th is report are w hether dentistry has complied w ith recom mended infection control procedures; the econo mic im pact compliance is having on dental practice; and how dentists perceive the larger issue of tre a tin g patients infected w ith the AIDS virus.
TABLE 1
INTENSITY OF USING BARRIER T E C H IE S I Ï TEAM INVOLVEMENT FOR AEE PATIENTS, I99I T E C H N IQ U E
D E N T IS T %
D E N T IS T A N D A S S IS T A N T /o
68
JADA, Vol. 123, March 1992
AND H Y G IE N IS T
% G LOVES
9 1 .8
76.1
8 7 .5
G LO VES, MASK
64.7
5 0 .0
6 0 .6
G LO VES, MASK, GOW N
6 1 .6
4 4 .2
53.3
GLOVES, MASK, GOW N, EYEW EAR
4 2 .5
2 7 .7
32.0
Source: ADA, 1991 Special version survey of dental practice.
about 12 percent said they wore gowns for all patients. D ental assistan ts seem to have m irrored the dentist’s p a tte rn
in adopting barrier techniques. I t was reported in 1986 th a t fewer th a n one in four assist ants used gloves, m asks or
TECH
H A S D E N T IS T R Y C O M P L IE D ?
Are dentists employing recom m ended b a rrier techniques? The evidence reported to the ADA since 1986 indicates th a t dentists and dental team m em bers are adopting standard b a rrier techniques a t a rapid rate. The use of gloves, m asks, and gowns by dentists on all p atients has increased th rough out the practice of dentistry and over tim e. Eyewear (both protective and corrective) has been used by about 80 percent of dentists since 1986 and has rem ained relatively steady. In 1986, slightly more th an 20 percent of dentists reported using gloves on all p atients and about the sam e percentage indicated using a m ask. Only
DE/MJt\ S T A S S IS T A N T
A L L P A T IE N T S 100
1986 □ 1988 91 1991
90 80 70
?—?1—
£ 60 IU
0 50 O C IU
a. 4 0 30
20 10
G LO V E S
MASK
GOWN
TECHNIQUE Source: ADA, 1986, 1988,1991 Special version survey ADA, Quarterly survey
EYEW EAR
INFECTION
TABLE 2
AVERAGE FEES BY PRACTITIONERS. BY HIGH VS. LOW BSE BF INFECT! CONTROL, 1990 PROCEDURE
LO W USER
H IG H USER
FEE D IF F E R E N C E
S
°/o
S
ORAL E X A M
17.74
15.73
12.8
R A D IO G R A P H
2 1 .7 2
2 0.25
7.3
P R O P H Y L A X IS
3 7 .4 9
3 3 .4 8
12.0
AM ALG AM
4 0 .97
3 7 .2 9
9.9
GOLD CROW N
4 6 2 .6 0
4 2 8 .4 0
8.0
UPPER
6 1 6 .7 0
5 48 .5 0
12.4
E X T R A C T IO N
5 2 .4 5
4 5 .44
15.4
ROOT CANAL
3 7 5 .5 0
3 4 5 .1 0
8.8
8 1 .8 7
7 6.74
6.7
DENTURE
P E R IO S C A L IN G
Source: ADA, Q uarterly Survey of D ental Practice.
th a n dentists. B ut th eir use of m asks and gowns reflected the relatively low usage of these
gowns for all dental patients. H ygienists historically have used gloves a t a higher rate
HYGIENISTS: BARRIER TECHNIQUES
A L L P A T IE N T S
io o
1986
LI 1988
B 1991
90 80
¿atm
70 2
60
111 0
E IU
50
Q . 40 30
20 10 O GLOVES
MASK
GOWN
TECHNIQUE Source: ADA, 1986, 1988, 1991 Special version survey ADA, Quarterly survey
EYEWEAR
C
O
N
T
b a rrier item s by dentists and assistants. Five years later, the picture had changed dram atically. By 1991, more th an 60 percent of dentists indicated using gloves, m asks, gowns or eyewear for all patients. Use of gloves has risen to more th a n 90 percent among dentists, hygienists and dental assistants. M ask utilization has climbed to more th a n 60 percent of dentists and assistan ts, and more th an 75 percent of hygienists. Use of gowns took a significant jum p in 1991 when 64 percent of dentists, more th an 75 percent of hygienists and about 60 percent of assistan ts reported using them . To delve deeper into the subject of compliance, the 1991 survey exam ined three key indicators: *■ the extent to which dentists use all techniques on all patients; ■* th e extent to which dentists and assistan ts use all techniques on all patients; and "■ th e extent to which dentists, assistan ts and hygienists use all techniques on all p atients in practices th a t employ a hygienist. The overall picture of how dentists are using b arrier techniques changes w hen one technique is m atched in combi nation w ith another (Table 1). For example, alm ost 92 percent of dentists indicated they use gloves on all patients, b ut 65 percent use both gloves and m ask. Sixty-one percent use gloves, m ask and gown, and ju st 43 percent use gloves, m ask, gowns and eyewear. Going a t th is another way, fully 91 percent of dentists, when not m easured w ith staff, use gloves for all patients. W hen glove use is m easured for JADA, Vol. 123, March 1992
69
R
O
L .
TABLE 3
practice dentist. Average gross billings PERCENT for 76% procedures rendered 69% have 53% advanced about 6.7 percent in 32% 1990 15% rising about 8.7 percent 11% each year since 1987. 11% Average an nual gross billings have exceeded the inflation rate since 1983. In 1990, the average net income from practice of dentistry reached $96,500. And since ’83, net earnings have advanced 6.7 percent per year compared to an annual inflation ra te of 4.0 percent. Total average operating
THREE MOST IMPORTANT ISSUES FACING DENTISTRY TODAY G E N E R A L IS S U E THE GENERAL ECO NO M Y O S H A R E G U L A T IO N S A ID S /H IV IN F E C T IO N C H A N G IN G P A T T E R N S O F D IS E A S E M A L P R A C T IC E IN S U R A N C E F L U O R ID A T IO N M ER C U R Y AM ALG AM
dentists and assistan ts together, compliance is 76 percent. For dentist, a ssista n t and hygienists combined, glove usage is 88 percent. About 28 percent indicated the dentist and assistan ts all use gloves, m ask, gowns and eyewear while tre a tin g all patients. In those practices employing a hygienist, 32 percent indicated the dentist, a ssista n t and hygienists all w ear gloves, m asks, gowns and eyewear to tre a t all patients. As a rule, practices employ ing hygienists show a generally higher proportion of all dental team m em bers using all the b arrier techniques for all patients.
expenses for dental offices rose a t a rate of 8.6 percent each year from 1987 through 1989, b ut jum ped about 11 percent in 1990. Salaries of non-dentist staff, dental supplies expenses and laboratory charges together account for about 56 percent of all operating expenses. Over the p ast three years, supplies expenses alone have increased 6 percent.after Laboratory charges have risen 7.5 percent and staff salaries are up 13.7 percent. Clearly, staff salaries are signif icantly boosting overhead expenses, reflecting the current shortage of office personnel. In 1990, dental fees increased an average of 6.7 percent against an inflation ra te of 5.4 percent. B ut the long-term inflation in dental fees (the p ast 20 years) has been 7.1 percent a year, lagging ju st behind an overall inflation rate of 7.2 percent. Rising practice costs p ut pressure on dentists to in
A L L P A T IE N T S
T H E E C O N O M IC IM P A C T
Guidelines for using barrier techniques are intended to boost the overall safety of patients, dentists and dental team m em bers. Their adoption affects tre a tm e n t procedures rendered in the dental office, practice costs and fees charged to patients. Between 1985 and 1990, overall economic conditions have improved for the private 70
JADA, Vol. 123, March 1992
TECHNIQUE Source: ADA, 1986, 1988, 1991 Special version survey ADA, Quarterly survey
INFECTION: CONTROL
crease fees, but inflation u n d er m ines the value of these fee increases. Com plicating dentistry’s economic scenario over the past few years has been growing concern w ith infection control procedures. These procedures, not surprisingly, are affecting practice costs and dental fees. E arly on, practitioners probably absorbed the costs for barrier techniques by adjusting the rate a t which th e techniques were adopted, by lowered n et earn ings or by offsetting ad ju st m ents in other expenses. More recently, there have been signs th a t dentists are beginning to pass on these added costs to p atien ts in the form of higher fees. The use of gloves, gowns, m asks, and eyewear all directly affect the dental office supplies budget regardless of w hether the dentists use the procedures on some or all the patients. Costs of dental supplies today account for roughly 10 percent to 12 percent of a practice’s to tal average expense. Over the p ast seven years, the supplies expense per patien t visit has increased from $6 per visit to about $12.50 a visit, a rise of about 108 percent w ithin the period. To compensate, gross billings per visit have increased 10.5 percent each year since 1986. O ther rising costs include overall supplies expense (11.1 percent a year); assistan t salaries (6.5 percent a year); and hygienist salaries (8.9 percent a year). Those adopting recom mend ed b a rrier techniques incur higher supply expenses per p atien t visit th an those who have not complied w ith the procedures or who use them only w ith some patients.
SUPPLY EXPENSE AND BARRIER TECHNIQUE
G Ps, 4TH Q U A R TE R , 1088, 1990 18
16
S i 6.35
$15.90
14
12 10 8 6 4
2 .
O 19 9 0
1988
YEAR USE OF BARRIERS
S o u rce:Q u arterly S urvey of D en tal P ractice
U S ER S NO N-USERS
U sing the 1991 survey data, general dentists were divided into: heavy users—dentist and a ssistan ts use gloves and m asks for all patients and w ear gloves, m asks and gowns for some patients; ■■ low users—either do not use b a rrier techniques or use gloves and m asks only for some patients. About 39 percent of general dentists and 38 percent of specialists are heavy users. N early 36 percent of solo dentists and 49 percent of dentists in non-solo practices are high users. High users are 44 years old on average. In 1988, the average supplies expense for heavy users was about $16.40 per patient visit. Low users spent about $10.85 per patien t for infection control procedures. As more dentists
w ent from low u sers to heavy users of b arrier techniques, this sharp difference declined. By 1990, average supplies expense per p atien t visit was $15.90 for heavy users vs. $11.90 for lower utilizer. I t’s also likely th a t this difference was fueled, in part, by a shortage of surgical gloves experienced in th e late 1980s, which had the effect of driving up costs. The use of b arrier techniques has also boosted the tim e den tists devote to each p atien t— donning gloves, m asks, gowns and protective eyewear, and properly disposing of the item s after use. As a result, heavy users of b arrier techniques see roughly 410 fewer patients each year and spend about six m in utes longer w ith each patient th an low users. These cost and tim e factors have lead to higher fees for dentists who are heavy JADA, Vol. 123, March 1992
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« N F E C T ,C E S S E S !
............... '
^
users of b ar rie r tech niques (Table 2). The average fee charged is greater among the general practitioners who are greater utilizers of the infection control pro cedures. The percentage difference ranges from a low of about 7 per cent for radiograph fees to a high of 15 percent for extrac tions. The average per cent differ ence in fees for the proce dures shown in Table 2 is about 10 percent. The compliance w ith infection control procedures affects dental practice costs, p attern s of practice am ong dentists, and procedure fees charged by dentists. D entists who are the heavier utilizer of the recom m ended b arrier techniques are experiencing about one-third higher supplies expenses, spending more tim e per patien t visit, treatin g fewer patien t visits per year, and charging about 10 percent higher fees. W H A T C O N C ER N S YOU?
The p ast couple of years have 72
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given U.S. dentists a lot to th in k about. OSHA regulations, a declining economy, lingering concerns about fluoridation, dental am algam and safety in health care settings have captured th e atten tio n of dentists everywhere. The ADA’s 1991 “Special Version Survey of Dental Practice” included a num ber of questions aim ed a t d entists’ attitud es and opinions on several m ajor issues (Table 3). The state of the economy was upperm ost in the m inds of three out of four dentists responding
to the survey. Close behind were OSHA regulations and HIV/AIDS infection dental am algam safety. Growing concerns w ith protec tion and safety m ean dentists and dental team m em bers are more likely to hear p atien t questions about barrier techniques. The special survey found th a t about 75 percent of the dentists had fielded patien t questions about the use of b a rrier techniques. About 70 percent also indicated th a t patien ts had discussed the techniques w ith th eir staff. Only one in five dentists said th eir p atients had n ’t asked about infection control procedures. New patients are less likely to inquire th an long-term patients. J u s t 2 percent of dentists said patients of record had asked about the d en tist being tested for HIV antibodies. On the other hand, th ree out of four dentists said they ask patients, in the course of gathering medical histories, about th eir
INFECTION
HE ISSUE WITH GREATEST IMPACT
CONTROL.
lesions norm ally associated w ith th e condition b u t did not inquire further. In addition, 22 percent have had a t least one p atien t they assum ed had AIDS or w as HIV positive only because of the p a tie n t’s appearance.
9 9 1
TH E YEARS AHEAD
GENERAL ECONOMY
OS H A REG S
H IV /A ID S
D IS E A S E P A TTE R N S
FLUORID A T IO N
D E N TA L AM ALGAM
ALL O TH ER
ISSUES Source: S pecial V ersion Survey, 1991
HIV/AIDS status. J u s t under a th ird of dentists responding said they had knowingly tre a te d a p atien t infected w ith HIV or AIDS. Most of these said they had learned the p atien t’s statu s m ainly through routine dental and medical inquiries, medical histories and other pre-treatm ent disclosures. Roughly 35 percent of
dentists said they learned of a p atien t’s HIV/AIDS condition by asking about it after noticing an oral lesion associated w ith the AIDS virus. M any dentists believed they had treated HIV/AIDS patients but had not asked the p atien t to confirm th eir suspicion. Tw enty percent of all den tists who believe they treated HIV/AIDS p atients found oral
The various factors described in th is paper have spurred dram atic changes in dental practice w ithin a very brief period. The ’90s will likely bring still greater change a t an everquickening pace. The new OSHA Bloodborne Pathogen S tandard, the longanticipated new guidelines from the C enters for Disease Control and growing professional and public concerns have and will continue to affect the practice of dentistry as reflected in rising costs and fees. The ADA, through its B ureau of Economic and Behavioral Research, will m onitor, analyze and report these developm ents as they occur in an effort to keep th e m em bership fully informed and prepared for the future. ■ T h is r e p o r t w a s p re p a r e d b y K e n t D . N a s h , P h .D ., d ire c to r o f th e A D A B u r e a u o f E co n o m ic a n d B e h a v io ra l R e se a rc h .
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