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00 R~nted tte A

FEB 0 6 1986

TIME UTILIZATION IN THE ARMY DENTAL CORPS -"i•

WALTER A. BRUSCH, DDS, MSD, MA, MSBA ""-

JAY D. SHULMAN, DMD, MA, MSPH .

FINAL DENTAL REPORT "#85-003 .

'~L° ... 1

September 19856

"" U Z US ARMY

HEALTH SERVICES COMMAND, MSBA

.FORT SAM HOUSTON, TEXAS 78234

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4. TITLE (end Subtitle) 5. TYPE OF REPORT & PCRIOD COVEkF.D

Tine~ iýtilization in the Army Dental Corps July 1983 to September 198E6. PERFORMING ORG. REPORT NUMBER q

DR85-003____7. AUTHOR(&) S. CONTRACT OR GRANT NUMBER(s)

Walter A. Brusch, UDS, NSD, [1A, HSBA I

Jay D. Shulman, DM0, MA, MSPH9. PERFORMING ORGANIZATION NAME AND ADDRESS 10. PROGRAM ELEMENT, PROJECT, TASK

U.S. Army H~ealth Care Studies and ARAliWRKUiTcUMER

Investigation Activity, U.S.A.Health Services CondFort Sam Houston, Texas 78234-6060 ____________________

11. CONTROLLING OFFICE NAME AND ADDRESS 12. REPORT DATE

U.S. Army Health Care Studies and Clinical September 1985Investigation Actv, U.S.A Health Services Command 13. NUMBER OFPAGES

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Approved for public release; distributioIo unlimited.

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18. SUPPLEMENTARY NOTES

DA30401 3

19. KEY WORDS (Continue on reverse side if necasaaiy end Identify by block numl.er)

duties, time utilization, practice profiles ..

20. ABSTRACT (Coo-tf=u.on r~ers. aid* It n~ce *aLy and identify by block number)

--Results from a survey of 1359 Army dentists are presented. Differences inArmy dental practice compared to civilian dental practice are illustrated.Tire utilization by Army dentists is examined by specific specialty groups.

* ~~General dentists' and specialists' times to perform specialty-commor procedures___are compared.

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TABLE OF CONTENTS

Report Documentaticn Page DD 1473 ii -

Table of Contents iii

Executive Summary I

I. Survey of Army Dental Practice

Introduction 3Methodol ogy 3Resu ts 4uDiscussion 9Conclusions 11 _______

7II Treatment ProFiles of Army Practice , -w"

introducti on 12Methodoiogv 12Results 12

Distribution of Treatment Time 13 -Treatment Time in Specialty-Common Procedures 15Treat•ent Profile by ?rocedure Group 15Procedures on Children 18Procedures Not Performed 19Patient Contact Time 19Productivity 20 V,Patient Categories 22Procedure Times 23

Discussion 24

Recommendations 30

References 31

Appendices

Appendix A Figures 32 '777-77 17Appendix B Tables 79 -Appendix C Survey of Army Dental Practice 90Appendix D Additional Army Data 96Appendix E Patient Encounter Form 117 -"Appendix F Procedures Not Performed 119Appendix G Procedures Performed Infrequently 121

Distribution List 122

' -*fiii-'''''-

117.

7.7

EXECUTIVE SUMMARY

Part I. SURVEY OF ARMY DENTAL PRACTICE

Data from a survey of 1359 Army dentists were compared with

the American Dental Association Survey of Dental Practice. More

Army dentists reported they used four-handed dentistry

techniques than civilian dentists. Army dentists also said theyL

had more assistants than did civilian solo dentists. Fiber optic

handpieces and panoramic X-ray units were used by more Army

dentists while electrosurgical and nitrous oxide analgesia units

were used by more civilian dentists. Civilian dentists schedule

a greater number of patients; however, the number of patients

* *treated by general dentists was about the same for both modes of

practice. More Army dentists reported that they were overworked

than did civilian dentists.

Part II. PRACTICE PROFILES OF ARMY DENTISTS

Procedure "overhead" (general procedures plus diagnostic

"procedures), the cost in time for making ready to treat,

accounted for 37% of all dentists' time. Both removable

prosthodontists and oral surgeons spent 39% of their time in

general procedures. In the case of removable prosthodontists,

they account for much of their interim pre- and post-prosthetic

> treatment time with procedures in the "general" category. In thecase of oral surgeons, half of the general procedures (such as

hospital ward rounds and cellulitis treatment) are more related

to what an oral surgeon does than to any other specialty.

- °-

" i12•1

Pedodontists spent a greater proportion of time in

prevention than any other specialty. Orthodontists spend more

time doing procedures in their specialty category than any other

Sspecialist. Since general dentists (63A) comprised the largest

group of dentists, they accounted for the greatest amount of time

spent in most procedure categories. On the D ther hand,

specialists accounted for a greater amount of time spent doing

difficult procedures.

Fixed prosthodontists achieved the highest productivity

measured in both weighted work units (WWUs) and "dollar" value.

- The fact that other specialists would have had to increase their

.: weighted work units by an average of 38% and their "dollar"

* *output by 88% to equal fixed prosthodontists, indicates an

apparent inconsistency in the procedure weighting process. WWUs

are a less distorting measure of productivity.

Commanders and clinic chiefs are only slightly less

".- productive than other specialists. Board eligible specialists

"were more productive than board certified specialists.

Generally, Army dentists spent more time treating active

duty personnel than any other patient category. The exceptions

were removable prosthodontists, pedodontists, orthodontists, and

o oral pathol ogi sts.

Specialists generally were faster doing specialty 1t

procedures, with the exception of oral diagnosis. The variation

-0 in procedure times was large.

2.1

I. SURVEY OF ARMY DENTAL PRACTICE. I

INTRODUCTION .

A strong element of similarity exists between military and

civilian dental practice; however, differences do exist. The

typical civilian dentist is self-employed and provides care in a

"private practice on a fee-for service oasis. In contrast, the

4-0 Army dentist is an employee, providing care in a group practice

for a salary. In addition, the Army dentist has dual roles as a

clinician ar! d a military officer.** The American Dental

Association provides current information on civilian practice. 1 e i

The same type of information has not been available for Army

dental practice. Previous studies have focused on military

specific problem areas. 2-3 The purpose of the Survey of Army- ..~~--... .-..*

Dental Practice was to obtain data with which to compare civilian,.' -

and Army dental pract,'e.

METHODOLOGY

During May 1984, all Army Dental Corps officers were

requested to complete a Survey of A Dental Practice (Appendix

C). This survey, in optical mark-read format, was patterned * ,.

after the 1982 American Dental Association Survey of DentalPractice.

** The Army dentist is involved in mandated military duties. 4 An

example is the training he receives each year to prepare to live

and work under field conditions and to provide acute trauma life

support to augment the physician's efforts during mass casualty

periods. This time is not included in the comparisons made

between civilian and Army dental practice.

3

0-.,-'1 ..-

The completed forms were read and analyzed using an SPSS

statistical package. For the purposes of this paper, the term

"general dentist" refers to a "general practitioner," a dentist

without residency training. Dentists who have had a two-year

general dentistry residency are referred to as general dentistry

specialists. The term "solo practitioner" was defined in the ADA

survey as a dentist who worked in a "solo dental practice." An"independent dentist" was defined "as one who is an owner, full V.

or in part, of a private practice." 1

RESULTS

Seventy seven percent (1359) of Army Dental Corps officers

responded to the survey. Because the distribution of dental

officers is highly skewed toward recent graduates (Figure 1),

median values are be to used to characterize Army dental practice

in Part 1. Comparisons of Army and civilian dental practice, in

Part 2, are made on the basis of means since this is how the data

were reported in the ADA survey.

PART 1: ARMY DENTAL PRACTICE

A profile of Army dentists is given in Table 1. It shows

that the "typical" Army general dentist is 31 years old, has had

no civilian practice experience, and has had four years of

military practice. He has moved twice, and has 16 more years to

a 20 year retirement.

The "typical" Army specialist is 40 years old, and like the

general dentist, has had no civilian practice. He has had 13

years of military practice, seven years experience in his

specialty, moved six times, and has eight more years to retire.

4

7-

As seen in Figure 2, virtually all Dental Corps officers who have

more than 10 years of service are dental specialists.

The proportion of Army dental specialists is shown in Figure * S

3. Thirty-one percent have achieved diplomate status. Three

percent have received special "professorial-level" recognition

from the Surgeon General for their professional achievements _ ,___"

(Fi gure 4).

Professional activities of Army general dentists and dental

specialists are shown in Figure 5. Eighty four percent of Army

general dentists have at least one state license, 75% belong to a

professional organization, and 95% reported attending at least

one dental meeting during the past year. Figure 5 also shows

that specialists are more likely than the general dentists to .. ..-.. -

have more than one state license, belong to more than one

professional organization, and to have publ is, -.d in a

professional journal.

The distribution of Army dentists' primary duties is shown

in Figure 6. The majority of dental officers listed "clinical

dentist" as their primary duty assignment. (Table 2) On the

other hand, more specialists cited other categories such as

"clinic director" or "program director" which require greater

experience and training. . --'•- 7-

Army Dental Corps officers are frequently assigned

additional administrative duties (Table 3). After "other

duties," "preventive dentistry officer," was listed more often by

general dentists as an extra duty, while more specialists

indicated "mentor." Additional data on Army dental officers is

5*•

57

"given in Appendix D.

PART 2: ARMY DENTAL PRACTICE VERSUS CIVILIAN DENTAL PRACTICE.

Comparisons between the Army survey and the ADA survey were

made on the following items:

year of graduation

*. hours per week in selected activities

S. :percentage of time treating patierts by type of

procedure

*" number of auxiliary personnel per doctor

-*"equipment included in practice

patient scheduling

perceived practice busyness

'. The average Army dentist officer graduated in 1974,

approximately ten years after his civilian counterpart in private

practice (Figure 1). How dental officers spend their practice

time in comparison to civilian dentists is presented in Tables 4

"and 5. Table 4 contains estimates for time spent in practice

activities, and Table 5 gives the proportion of treatment times

spent in performing selected dental procedures. Army dentists

reported they spend 33.4 hours per week treating patients, while071

the ADA Survey reported that civilian solo dentists and

independent dentists spend 32.0, and 32 4 hours per week,

r respectively. Army general dentists had the longest amount of

patient treatment time: 35.4 hours versus 32.4 for the

independent civilian dentist and 32.1 for the solo civilian

dentist. Army specialists report spending slightly less time per

6

40

week treating patients (30.3 hours) than either solo specialists

(31.3 hours) or independent specialists (31.7 hours). N

Professional reading accounted for 4.7 hours of the Army _ -__

specialist's week, almost twice as much time spent than either N .

the solo specialist or the independent specialist (2.4 and 2.5

N hours respectively). All categories of Army dentists reported

spending more time in administrative and clerical activities than .

their civilian counterparts. Army dentists said they spent an

average of 3.2 hours per week completing records compared to

independent dentists who reported 1.9 and solo dentists who

reported 1.8 hours per week filing pre-payment forms and

bookkeeping. .- ,

Army dentists reported spending more time in diagnosis and

less time in preventive acti vities (10.8% and 3.6%) than did the

solo civilian (9.6% and 9.5%) or the independent civilian dentist

"(9.6% and 8.6%). Civilian dentists reported spending more

time in operative dentistry (38.0% dnd 37.5%) than Army

practi ti oners (27.7%). Dental officers spent more time in S,

prosthodontics (17.6%) than either category of civilian dentist

(14.4% and 14.8%). The same trend was evident in the practice of

oral surgery with Army dentists spending more of their time in

surgical procedures (11.0%) than both categories of civilian

dentists (6.5% and 6.5%). Army specialists reported spending

almost twice as much time in diagnostic procedures: 14.3% versus

7.5% and 7.9% for -he solo and independent specialists.

Table 6 makes comparisons for number of chairside

assistants, types of equipment available, number of operatories

utilized, and work simplification techniques. Army dentists

7

- - -..- - - -

report having slightly more dental assistants than do civilian

solo dentists (1.5 versus 1.2 respectively). More Army dentists

report using ':four-handed dentistry" techniques (62.4%) than

either solo or independent dentists (54.2% and 57.3%), although

Army dentists also reported they had fewer operatories available

to them (1.8) than did their civilian counterparts (2.6 and 3.2).

There was little difference between civilian and military

dentists in the use of light cured composite restorations. More

Army dentists, however, use fiber optic handpieces and panoramic

X-ray units than civilian dentists. On the other hand, fewer

Army dentists use electrosurgical units and nitrous oxide

analgesia than do their civilian counterparts.

Table 7 compares the number of patients seen per week by

civilian and Army dentists. Although Army and civilian dentists

spend about the same amount of time per week treating patients

(Table 6), Army dentists see a larger n "mber of non-scheduled

patients than either civilian category; Army dentists also

schedule fewer patients per week than solo and independent

dentists (43.4 versus 58.1 and 58.9). Civilian specialists

reported scheduling twice as many patients per week within

virtually the same amount of treatment time as Army specialists:

90.4 and 91.0 for solo and independent specialists versus 40.4

for Army specialists. Civilian patients wait only half as long

as Army patients for an appointment (7.7 days versus 18.2 days).

Patients waiting time in the reception room after arriving for an

appointment is about the same for both modes of practice.

8,j-J

Dentists' perceptions of practice busyness are compared in

Figure 7. Fifty-nine percent of all Army dentists said they

were too-busy or over-worked versus 15.4% of the solo and 14.6%

of the independent dentists (Table 8). Army specialists rate

their practices even busier: 65.4% said they were too busy or

overworked versus 7.8% and 7.5% for solo and independent

specialists, respectively.

DISCUSSION

A comparison of the ADA survey with the Army survey shows %

that while these two modes of practice are similar, differences

do exist. The Army Dental Corps has more recent graduates thanr

civilian practice. This is not surprising for two reasons: agreater proportion of graduates choose working for the .uderal

services initially, 5 and Army dentists are precluded from serving

more than 30 years in the Dental Corps. Certain types of ______

equipment such as panoramic X-ray units were used by more Army

dentists. One would expect that where patient volume is 'arce

enough, such as in an Army dental clinic, there wotld be greater

justification to purchase such equipment. On the other hand,

fewer Army dentists use electrosurgical units and nitrous oxide

analgesia than civilian dentists. This is due to a credentialIng

process which limits access to these treatment modalities to

those especially trained to use them. Civi1ian practitioners '

typical ly schedule more patients per week than Army

practitioners and their patients have a shorter time to wait for

an appointment. Howcver, the number of patients treated per week -\ ;.

by general dentists is about the same for both modes of practice.

Civilian specialists schedule twice as many patients within

9

virtually the same amount of treatment time as Army specialists.

A logical inference is that Army specialists choose to scheduleQ)

longer appointments. Appointment scheduling behavior within theL

civilian sector probably is the result of practice marketing N

"strategies. Given a relatively fixed treatment period, seeing

more patients in shorter appointments both reduces patients'

waiting times for appointments and may increase consumers'

acceptance of the dental fee if they are seen often and the

charges are not too great per dental visit. A consequence of

more frequent appointments is increased patient handling time

resulting in decreased efficiency and increased cost of dental

care in the long run. Army specialists reported spending almost

twice as much time in diagnostic procedures as the civilian

specialist. This may be partially explained by the fact that one

"out of every five Army specialists is involved either as a

program director or mentor in a dental postgraduate training

program. Finally, nowhere is the gulf between military and

civilian lentists wider than their antipodal attitudes towards

practice busyness: the civilian responses clustering about "not

being busy" and the military responses clusterinc about "being

too busy." Army dentists may feel they are too busy because

they have a seemingly never ending patient pool seeking their

s services and al so no matter how hard they work, their

re~nuneration remains constant. On the other hand, civilian 1

dentists may feel that their patient pool is limited and they

would like to be busier since their income is based on a fee for

service rendered.

10

CONCLUSIONS

Our results suggest that while both Army dentists andcivilian dentists practice the same profession, there are

differences based on practice management strategies which affect

both patient scheduling behavior and perceptions of busyness.

Training needs of the Army Dental Corps also influence how Army

specialists practice. Constraints imposed by individuaI

dentists credentialing limits access to certain modalities oftreatment within the Army Dental Corps.

-I

-'4

K

r.

k'

II. TREATMENT PROFILES OF ARMY DENTAL PRACTICE

INTRODUCTION

The final part of the study describes practice profiles of

Army dentists. Selected demographic variables from the Survey of

Army Dental Practice were examined to determine their

relationships to distribution of dental treatment, categories of

patients, time to perform dental procedures, and dental

productivity.

METHODOLOGY

Provider characteristics from the Survey were related to

dental procedure data. Procedure data were collected in Health

Services Command dental treatment facilities 1 - 31 May 1984 for

a period of 22 working days. These data included patient7 category, the time the patient entered and left the treatment

"area, procedure code for treatment, time interval for each

procedure, the level of ancillary support, and perceived

treatment difficulty (Appendix E). Real-time measurements were

not made during dental treatment but rather recorded time

intervals were based on dentists' ability to recall estimated

treatment times at the end of the appointment.

Unless otherwise indicated, the following data exclude

students and dentists in specialties with fewer than 10 members

(Oral Medicine n=3, Public Health n=5, and Oral Pathology n=9).

RESULTS

During the study period, 896 dentists recorded 200,939

patient encounters and time measurements on 858,000 dental

12

procedures. The encounter and survey data bases were merged by

specialty skill identifier (SSI) and social security number(SSN). Data on forms containing invalid SSI or SSN fields were

omitted resulting in a loss of approximately 100,000 procedures

(12%).

DISTRIBUTION OF TREATMENT TIME

The distribution of all categories of dentists' treatment

time by procedure group is shown in Figure 8, Restorative

procedures accounted for the greatest use of treatment time

(30%). General procedures (20%) and diagnostic procedures (17%)

add up to 37%. Preventive procedures accounted for eight percent

* of the time.

The practice patterns of general dentists and general

dentistry specialists are similar (Figure 9). Where differences

e exist, they are in diagnosic and restorative time. General

dentistry specialists spent more time in diagnosis (19% versus

15%) and less in restorative procedures (31% versus 39%) than

general dentists. The specialist also spent slightly more of his

time in prosthetics, but they spent equal time in prevention (7%)

S , and surgery (6%). Reported orthodontic procedure time was less

*O than one percent for both groups.

"Treatment time of periodontists and endodontists is compared

in Figure 10. The most striking differences are in preventive,

* restorative and surgical procedures. Periodontists report seven

times more preventive time and five times more oral surgical

time. On the other hand, endodontists report five times more

* * treatment time spent in restorative procedures. Both spent about

13

the same amount of time in oral diagnosis (26% and 25%

respectively).

How prosthodontists allocate their treatment time is shown

in Figure 11. The most prominent feature is the difference in

time spent in diagnostic and general procedures. Removable

prosthodontists spent 58% of their time in these two categories,

"V versus 37% for fixed prosthodontists. Both spent about the same

proportion of time in preventive procedures. Fixed

prosthodontists spent a greater proportion of time in restorative

(17% versus 8%) and periodontic procedures (10% versus 6% for

removable prosthodontists). Fixed prosthodontists also reported

spending two percent of their time in removable prosthodontics

and one percent in endodontics. The practice profile of oral

surgeons is shown in Figure 12. They spent 39% of their time

doing adjunctive general procedures (the same as removable

prosthodontists), which is more time than they spent on oral

surgery procedures (31%). Diagnosis accounted for 23%, and

periodontics and orthodontics each accounted for one percent.

Five percent of the oral surgeons' time was devoted to preventive

dentistry.

Figure 13 shows how pedodontists and orthodontists divide

their practice time. Orthodontists spent 56% of their time in

their specialty, a larger proportion of time than other

specialists. They also spent less time in adjunctive general

procedures (14%) than other specialists. Nineteen percent of an

orthodontist's time was in diagnosis and 10% in prevention.

Periodontics procedures accounted for one percent.

14

The largest amount of the pedodontists' time was spent in

preventive related procedures (24%), followed by adjunctive

general procedures (22%), and restorative procedures (21%).Orthodontics accounted for eight percent, fixed prosthetics for

six percent, periodontics and oral surgery each accounted for two

percent, and endodontics for one percent of pedodontic time.

TREATMENT TIME IN SPECIALTY-COMMON PROCEDURE GROUPS

Figures 14-17 give the percentage of time each group of

specialists spent in diagnostic, preventive, restorative and

general procedure groups. Oral medicine specialists, oral

pathologists and public health dentists spent most of their

treatment time in oral diagnosis and periodontists, endodontists

and oral surgeons spent about one-fourth of their time in

diagnosis (Figure 14). Pedodontists, periodontists, and

orthodontists each spent over 10% of their time in preventive

procedures; endodontists spent the least amount of time in

prevention (Figure 15). Both general dentists and general

dentistry specialists each spent over 30% of their time in

restorative procedures (Figure 16). Removable prosthodontists

".. and oral surgeons each spent almost 40% cf their time in general

procedures (Figure 17).

TREATMENT PROFILE BY PROCEDURE GROUP

The following data show how procedure group treatment time

is apportioned among the dental specialties. The data are

sensitive to the numbers of dentists within each group. Since

. general dentists (63A) comprise the largest group (n=543), they

accounted for the largest proportion of time spent within many of

15

the treatment categories. An illustration of this is the

•-. distribution of diagnostic time in Figure 18 waich shows thatgeneral dentists accounted for almost twice as much of the

diagnostic time (55%) as all categories of dental specialists put%

~ together (29%).

Figure 19 shows that 57% of the time spent in preventive

procedures was accounted for by general dentists. General

dentistry specialists (n=120) and pedodontists (n=23) each

accounted for 10%, periodontists (n=53) for seven percent, and

removable prosthodontists (n44) fotir percent. Fixed

-. prosthodontists (n=42), orthodontists (n-24) and oral surgeons

(n=40) each accounted for three percent and endodontists (n=38)

one percent.

F Figure 20 shows that virtually al 1 the time spent doing

restorative dentistry was spent by general dentists: 63A (81%)

and 63B (12%). Fixed prosthodontists and pedodontists are next,

each with two percent, followed by endodontists and removable

"prosthodontists, each with one percent.

A breakdown of endodontic time is shown in Figure 21. Both

categories of general dentists together accounted for twice as

much of the endodontic time as endodontists (66% versus 33%).

* 0 Fixed prosthodontists and pedodontists each accounted for one

percent of the time. Figure 22 shows a profile of selected

endodontic procedures. More time was spent doing bleaching and

* one-canal root canals by general dentists than by endodontists.

"On the other hand, more time was spent by endodontists doing

molar root canals than by general dentists and general dentistry

9, specialists.

16

The distribution of periodontic time is shown in Figure 23.

Most time in periodontics was spent by general dentists (51%)

followed by periodontists (32%) and general dentistry specialists

(11%). Figure 24 shows that most of the periodontic practice

time of general dentists was spent scaling and doing occlusal

adjustment while most periodontists' time was spent in root

planing and surgical periodontics.Forty-two percent of the time in removable prosthodontists

was accounted for by removable prosthodontic specialists versus

38% for general dentists (Figure 25). General dentistry

specialists accounted for 14% and fixed prosthodontists five

percent of the time. Fixed prosthetics time distribution is

shown in Figure 26. Both categories of general dentists (63A and

* - 63B) accounted for 67% of time spent in prosthetics versus fixed

prosthodontists which accounted for 27% of the time. General

dentists provided almost twice as much fixed prosthetic treatment

time as prostnodontists.

Distribution of surgical time is shown in Figure 27.

General dentists accounted for approximately three times more

oral surgery time than oral surgeons. General dentistry

specialists accounted for 12%. Figure 28 shows which surgical

procedures general dentists (63A and 63B) spent most of their

time doing. Both categories of general dentists accounted for

47% of simple extraction time and 43% of complicated extraction

time versus 10 and nine percent respectively, for oral surgeons.

Time spent doing impactions was almost equally divided between

the two categories of general dentists and oral surgeons while

17

-0•

50% of all "other" oral surgery time was spent by oral surgeons

compared to 22% and 29% for 63As and 63Bs respectively.

General adjunctive procedure time was apportioned in the

following manner: General dentists 58%; general dentistry

specialists 12%; removable prosthodontists and oral surgeons,

eight percent each; periodontists and pedodontists, each three

percent; and endodontists and orthodontists, two percent each

(Figure 29).

PROCEDURES ON CIIILDREN

The profile of selected dental treatment dono on children is

shown in Figires 30-32. Fifty-four percent of uncomplicated

extraction time on children was spent by general dentists.

Pedodontists accounted for 24%, general dentistry specialists for

io:- nine percent and oral surgeons for 12% (Figure 30). The picture

changes somewhat when the profile of impacted extractions is

examined. Oral surgeons accounted for most of the impacted

w. extraction time (57%) versus 35% for the general dentists.

"-" General dentistry specialists accounted for 10% and pedodontists

accounted for only one percent of impacted extraction time on

c h ild ren .

Figure 31 shows that most one-surface amalgam time was spent

by general dentists while most deciduous pulpotomy time was spent

by pedodontists, and about an equal amount of periodontal scaling

time was ac;counted for by general dentist and pedodontists.

Orthodontists accounted for more periodontal scaling time than

periodontists or general dentistry specialists. A profile of

selected orthodontic procedures is shown in Figure 32, Although

18.Z1

there are five times as many general dentists as there are

general dentistry specialists, the farmer accounted for 10 times

more simple hawleys, space maintenance appliances, and banding

time as general dentistry specialists. Orthodontists spent more

S time in banding and simple hawley appliances, while pedodontists

spent more time in space maintenance appliances.

PROCEDURES NOT PERFORMED

Twenty-six procedures were not recorded on the patient

S encounter forms during the study period. A list of these

procedures is given in Appendix F. General procedures,

restorative, endodontics, periodontics, and orthodontics each

* accounted for one, oral surgery for three, and removable

prosthetics accounted for 17 of the nor-used procedures.

-, '• Appendix G lists 137 procedures that were peeformned infrequently

* (n = <100).

PATIENT CONTACT TIME

-, Daily contact hcurs, thn time actually spent performing

dental treatment is shown in Figure 33. The greatest amount of

treatment time was by pedodontists, who provided 4.5 hours of

direct patient care followed by generai dentists who provided

four hours. The other specialists' times ranged from 3.0 to 3.4

.- treatment hours with an average of 3.5 hours of direct treatment.

The effect of additional duties is shown in Figure 34. Dentists

who are not assigned extra duties average 3.8 hours in direct

, treatment. Mentors in a trai ing program and clinic directors

.;• spent slightly less time trea-ting patients (3.3 and 3.4 hours

Srespectively). A commander of a dental activity was able to

-. -. 19

spent only one-fourth of the patient contact time as a dentist

Z:• not assigned additional duties (0.9 versus 3.8 hours per day).

PRODUCTIVITY

Weighted work units 6 per contact hour is shown in Figure

35. Fixed prosthodontists produce 11 weighted work units (WWUs)

per direct contact hour, followed by periodontists and removable

* prosthodontists who each produce nine WWUs per hour. Al1l other

specialty groups produce eight WWUs except for endodontists who

average seven WWUs per hour. Daily weighted work units are shown

in Figure 36. Fixed prosthodontists produce 38 WWUs per day

followed by pedodontists who produce 35 WWUs per day. General

dentists, general dentistry specialists, and removable

prosthodontists are next with 31, 27 and 27 WWUs, respectively.

Oral surgeons produce 26 WWUs per day followed by endodontists

and orthodontists who each produce 25 per day. The fewest (23%(

WWUs per day) was produced by periodontists.

Figure 37 shows "dollars"6 produced per contact hour by

dental specialty. Fixed prosthodontists produce 229 "dollars"

for each hour of direct patient treatment. They are followed by

periodontists and removable prosthodontists who produce 158 and

141 "dollars" per hour resiectively. Next are endodontists with

128, oral surgeons with 122, general dentistry specialists with

119, pedodontists with 105, and general dentists with 100

dollars per hour. The smallest amount of "dollars" per hour was

produced by orthodontists (89 per hour). Dol lars produced per

day by specialty are shown in Figure 38. Fixed prosthodontists

produce 764 "dollars" per day. Periodontists and pedodontists

•• 20

'I

.t..

are next with 538 and 469, respectively. Endodontists and

removable prosthodontists produce 429 and 425, respectively.

Next are general dentists with 409, general dentistry

specialists with 388 and oral surgeons with 386 per day. The

least amount (298 "dollars") was produced by orthudontists.

Figure 39 gives the percentages by which the other dental

specialties would have to increase their daily contact hours to

equal the number of weighted work units and "dollars" to equal

that produced by fixed prosthodontists. Orthodontists would

have to increase their patient contact hours by 156% (a factor of

2.56) to equal the "dol l ar" amount and 48% (a factor of 1.48) to

equal the WWUs produced per day by fixed prosthodo:ntists.

General dentists would have to work 128 percent more time and

47% more time to equal fixed prosthodontists' WWUs and "dollar"

output. The average percentage increases for the other

specialists are 88% and 38% for "dollars" and WWUs.

The productivity of commanders and clinic chiefs versus

specialists is shown in Figure 40. Commanders and clinic chiefs,

who are assigned additional administrative duties, average about

60 "dollars" less productive output than other specialists. The

only exception was orthodontists who produced the same amount.

The productivity of non-mentor board certified and board eligible

specialists is shown in Figure 41. Board certified specialists

averaged 116 "dollars" less productive output. The only

exception were board certified pedodontists who averaged 65

"dolI lars" per day than their board el igible counterparts. The

productivity of all specialists versus mentors is shown in Figure

21

42. Mentors, which included full as well as part time mentors,

averaged 123 "dollars" less productive output per day than non-

mentors. However, mentors in periodontics, removable

prosthodontics and orthodontics produced more than non-mentors.

PATIENT CATEGORIES

The distribution of treatment time provided different

patient categories by each dental specialty is shown in Figure

43. The distribution of patient categories treated is shown in

Figure 44.

General dentists and general dentistry specialists spent

61% and 62% of their time treating active duty soldiers and

soldiers also make up 62% and 64% of the patients they treat.

Fixed prosthodontists spent the largest amount of time treating

soldiers (69%) who comprise 70% of the fixed prosthodontists'

practice. Removable prosthodontists spent more time treating

retirees (45%); however, they treat a larger proportion of

soldiers than retirees (43 versus 36 percent). Public health

dentists spent 80% of their time treating soldiers, who made up

92% of their practice. Pedodontists' and orthodontists' time was

almost all taken up treating children (96 and 89%) and 96% and

89% of the patients treated by pedodontists and orthodontists

were children. The specialists who came closest to spending an

'- equal amount of time on each patient category were oral

pathologists (34% active duty; 36% dependents; and 27% retired).

22

0L

PROCEDURE TIMES

Average procedure times by years of practice is shown in

Figure 45. In general, up to 15 years, the average time per

procedure remained fairly constant at about six minutes; from 16

to 23 years the average time increased to seven minutes; and

later decreased to 5.5 minutes after 24 years of practice. The

overall average was 6.3 minutes. Average procedure time by

specialty is shown in Figure 46. Prosthodontists spent the most

time per procedure (7.9 and 7.8 minutes for removable

prosthodontists and fixed prosthodontists, respectively); next

were periodontists with 7.4 minutes. Specialties which spent the

least time per procedure were orthodontists (5.0) pedodontists

(5.5), oral surgeons (5.8) and general dentistry specialists who

spent and average of 5.9 minutes per procedure. Generally, when

perform~ance times for specialty procedures by specialists were

compared to both categories of general dentists, specialists were

faster. The exception was oral diagnosis where oral medicine

specialists and oral pathologists took more time to do oral

examinations. General dentists' and specialists' times to

perform selected procedures are shown in Table 9. The

coefficients of variation associated with the procedure times

averaged 105% (2.9% - 435.8% range LTable 10]).

23

DISCUSSION

The data presented do not account for the dentists' total

time but rather are the sum of procedure times or "hands-on-

treatment time" only. Since the study was conducted during one

month rather- than the entire year, a secular bias was introduced.

May is a month when many dental officers are preparing for a

change of duty station and attempting to complete treatment on

their patients. An additional distortion was introduced in that,

. at times, there were only one or two specialists in a particular

year group.

S.-Although a record was made of the dentists' perceived

procedure difficulty and the amount of ancillary support provided

0• at each procedure, the summary data presented do not take into

account these two variables. Not all dentists had the same level

of ancillary support or the same access to multiple operatories.

i A greater level of ancillary support and more operatories allow

dentists to do more. A particular procedure may vary in degree

of difficulty and a harder procedure takes longer. Estimates of

the difficulty of a pr,'cedure are largely subjective and depend

to a great extent on the skil I level of treating dentist.

Caution dictates that more difficult cases are treated by

* 0 specialists. In addition, time intervals for procedures were not

adjusted for repeated procedures. A procedure which is repeated

-N would normally take less time since the provider increases his

D speed doing repetitive tasks. Neglecting the analysis of these

.>. variables tends to introduce a greater variation in time

Srecording. This is demonstrated by the large coefficients of

v variation associated withprocedure times whichaveraged 105%.

24

'a.

A loss of approximately 12% of the procedure data was

encountered when patient encounter data were merged with Survey

data. If the procedure loss was distributed in a random manner

it would have little effect on the proportions in the descriptive

statistics. For this reason, the report examined relationships

between groups in their profiles of dental practice.

General procedures and diagnostic procedures for all

denti sts totaled 37%. In accounting terms these two categories

would be considered overhead, or the time cost of making ready to

provide treatment. The least amount of time recorded for all

dentists was for fixed prosthetics and orthodontics.

A comparison of the general dentist and general dentistry

specialist shows that the general dentistry specialist spent

more time in diagnosis. Since much of the residency training he

receives is in oral diagnosis, it foilows that he might place

greater emphasis on a through history and examination in

treatment planning his patients. Also by virtue of his training,

the general dentistry specialist is sent the more difficult cases

at the initial dental triage. Although the general dentistry

specialist does slightly more prosthetics than the general

dentist, a proportionately greater time is not similarly spent in

endodontics, periodontics, or surgery. This would indicate there

is less need for the general dentistry specialist to fill the

role of a surrogate specialist in these fields.

In the comparison of periodontists' and endodontists' time

it can be seen that the proportion of a specialist's time depends

on the t-eatment modality characteristics which distinguish that

25

specialty. Periodontists spent more time in prevention because

good patient oral hygiene plays an immediate role in the success

of periodontal treatment. Also, there is a continuity between

periodontal surgery and oral surgery procedures so periodontists

• ' spent more time doing oral surgery. General ly, an

endodontically treated tooth needs a restoration, so endodontists

spent more time doing restorations.

The fact that removable prosthodontists spent more time in

diagnosis and general procedures than fixed prosthodontists may

be due to a greater dependence on patient compliance for

successful outcome of treatment. More than most other patients,

* denture patients have to learn to tolerate and care for their

-. removable appliances so patient compliance may be a greater

factor in the success of removable prosthetics. It follows that

where patient selection, education, and motivation are essential

0 treatment elements, a greater proportion of the provider's time

will be spent in diagnosis and general procedures. A large

"proportion of time spent in general procedures by both types of

prosthodontists is mandated by an accounting system which gives

credit for prosthetic appliances and restorations only at

insertion. In order to account for interim pre- or post-

* treatment time, general procedures, such as post operative

treatment, dental cast, or diagnostic mounting procedures are

taken. Fixed prosthodontists spent more time doing restorative

* and periodontal procedures since both of these treatment

modalities are prerequisites for successful fixed prosthetic

treatment.

* '.

N°6

At least half of adjunctive general procedures, such as

hospital ward rounds and cellulitis treatment, are more related

to what an oral surgeon does than to any other specialty. So it

is not surprising that a large proportion of time (39%) was spent

in general procedures.

Unlike other specialties, pedodontists do not have a

specialty-unique procedure category, so their time was divided

between other specialty procedure categories. Pedodontists spent

a greater proportion of time in preventive related activities

than all other specialists which may indicate either a greater

emphasis on prevention for the child dental patient or a greater

need by children for preventive procedures. Pedodontic practice

has been characterized as general practice on children. However,

a comparison with that of general dentists reveals that the

practice patterns are different. Besides the large proportion of

time spent in prevention, the most apparent differee the

lesser amount of time given to restoring teeth and the greater

amount of time spent doing orthodontic procedures. It is

noteworthy that general procedure time, which includes patient

handling, part of which is dealing with behavioral problems, was

similar for both pedodontists and general dentists.

The fact that orthodontics accounts for 56% of

orthodontist's time and the fact that most other specialists do

not spent time in orthodontics, indicates either that orthodontic

treatment has less dependence on other specialties for a

successful outcome or that the treatment plan has specified that

patients' other dental needs have been met prior to initiating

orthodontic treatment.

27

wr

S Since general dentists comprise the largest group, they

accounted for the greatest amount of time spent in most procedure

categories, however, specialists accounted for a greater amount

of time doing difficult procedures; e.g., molar root canal

treatment, surgical periodontics, impactions, space maintainers

and banding procedures.

Fixed prosthodontists achieved the highest productivity

measured in both WWUs and "dollar" value. The fact that other

specialists would have had to increase their weighted work units

by an average of 38% (1.38 times) and their "dol lar" output by

88% (1.88 times) to equal that of fixed prosthodontists,

indicates an apparent inconsistency in the dollar weighting

process. It would appear that WWUs are a less distorting measure

of productivity.

Commanders and clinic chiefs are only slightly less

productive than other specialists. Board eligible specialists

were generally more productive than board certified specialists.

In five of the specialties mentors produced less than non-

mentors, while in three specialties they produced more.

In general, active duty personnel made up the largest

proportion of patients treated and accounted for most treatment

time within each specialty category. The exceptions were

removable prosthodontists who spent more time with retirees, but

treated more soldiers; pedodontists and orthodontists who treated~llI mostly children; and oral pathologists who treated almost an

equal number of retirees, dependents, and active duty soldiers.

28

Average procedure times by years of practice showed some

increase after the 15th year and a decrease after the 23rd year.

This difference could be due both to differences in practice

experience as well differences in mix of treatment procedures K.within each year group. Differences in average procedure time

by specialty reflected the fact that removable prosthetic

) procedures take more time and that orthodontic procedures take

less time than other specialty procedures. Specialists generally 11

were faster doing specialty procedures with the exception of oral

d diagnosis. .

> " Several points need to be stressed in the interpretation ofthe procedure time data. The first is that it is difficult to

assess how accurate they are. Although instruction was given to

participants that times were to be recorded at the end of each*."

patient encounter, there are anecdotal reports of participants -,

estimating the times at the end of the day. The practice of

retrospective estimation cou.d account, in part, for the large

variations in the reported procedure times. In addition,

procedure times are sensitive to other factors such as the

difficulty of the procedure, number of repetitions, the level of

ancillary support and the experience of the dentist. Only a

multivariate analysis, incorporating these variables and

, interactions among variables, and weighting their effects, at a

minimum, could possibly make sufficient; adjustment to make the

procedure times comparable.

29

if." 29.0i'

RECOMMENDATIONS

1. The Survey of Army Dental Practice provides valuable

information on demographics of the Dental Corps. A survey of-. '3 this type shou'ld be repeated, either on an regular or on an as

~ ~ 1473ý_ _ needed basis.

2. Practice profile information obtained in the current study

provides useful management information on procedure practice and

"patient category mix of each dental specialty. These data

_should be made available to dental managers for personnel and

facil ities planning.

3. Procedure time interval col lected within this study were

subject to great variation. Post-treatment self reporting of

time intervals, differences in experience and training,

differences in level of ancillary support, and lack of an

objective measure of procedure severity were possible sources of

-. variation. Studies on dental procedure times need to minimize

these confounding variables either directly, or if possible,

"- factor out their effects to allow comparisons. A similiar i..

management study on procedure times should be done when a non-

invasive real-time procedure reporting system, utilizing direct

- computer data entry (voice, touch screen, etc.), is available.

This will eliminate retrospective procedure time estimation.

30

REFERENCES:

1. Survey of Dental Practice. Chicago, Bureau of Economic

and Behavioral Research, American Dental Association, 1983.

2. Schumaker, C.J. Selected Measures of Denti sts'

Productivity: Self-reported. Health Studies Task Force Report,

Washington DC, Office of the Assistant Secretary of Defense

"(Health Affairs), 1979.

3. Schumaker, C.J. Dentist Survey 1979: Summary Repqot.

Health Studies Task Force Report. Washington DC, Office of the

Assistant Secretary of Defense (Health Affairs), 1979.

4. Memorandum for the Assistant Surgeon General, Chief,

- Army Dental Corps. Subject: Availability of Treatment for Dental

* Crops Officers. 17 April 1985.

5. House, D.R. Occupational choice and labor supply

decisions: the case of the licensed dentist. In Brown, L.J, and

Winslow, J.E. Proceedings of a Conference on Modelinq Techn*iues

and Applications in Dentistry. Washington D.C., U.S. Department

of Health and Human Services, DHHS Publication NO. (HRA) 81-8,

* 1981.

6. Uniform Chart Of Accounts For Fixed Military Medical

SAnd Dental Treatment Facilities (Change No. 4). Office of the

o' Secretary of Defense, Assistant Secretary of Defense (Health

Affairs). Department of Defense Publication System. June 17,

* * 1983.

31

; APPENDIX A

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80

TABLE 2

DUTY ASSIGNMENT (%)*

ALL GENERAL DENTALDENTISTS DENTISTS SPECIALISTS

CLINICAL DENTIST 69.9 81.9 54.3

PROGRAM DIRECTOR 2.3 0.5 4.8CLINIC DIRECTOR 14.4 6.3 25.2

UNIT COMMANDER 3.5 0.1 7.4""" LABORATORY OFFICER 0.3 0.1 0.6'.•

HEADQUARTERS STAFF 1.0 0.4 1.9

ACADEMY INSTRUCTOR 0.3 0.2 0.5

RESEARCH POSITION 0.8 0.2 1.4

OTHER 7.5 10.4 3.7

Percentage of responses listed. Respondents are assigned"one primary duty which is exclusive of other duties, thus totalof responses, in each categoryequalslO0%.

f

81

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TABLE 3

ADDITIONAL DUTIES (%)k

ALL GENERAL DENTALDENTISTS DENTISTS SPECIALISTS

PREVENTIVEDENTISTRY OFFICER.-. 16.0 21.6 8.6

PHYSICAL TRAINING"OFFICER ............. 5.2 5.8 4.4

DEPUl fCOMMANDER ........... 5.1 1.6 9.8

SUPPLYOFFICER ............. . 12.1 13.8 9.8

EDUCATIONt OFFICER ............. 10.8 8.1 14.3

PRECIOUSMETALS OFFICER ...... . 15.7 33.5 18.7

PROGRAMMENTOR ............... 13.4 1.8 28.7

OTHERDUTIES .............. 78.1 80.9 74.3

* Percentage of cases 7isted. Respondents may be assigned•. severaladditionalduties;totalof responses may exceed 100%.

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.1 ~APPENDIX CL

A SURVEY OF MILITARY DENTAL PRACTICE

411

*9

SURVEY OF MILITARY DENTAL PRACTICE now

[OFFICER CHARACTERISTICS COMMISSION

DAT POSTTAE S1 RA USARL

-1DATE LAST FOUR SSN AAS

, " " i-] . .. H FVTTHE MOST ACCURATE DESCRIPTION(S)

,LI] L I L[63 9 OF YOUR DUTY ASSIGNIMENT(S)0! 0 , I 0 ! 0 O 0 0 ,"0 ) PROG;RAM DIRECTOR

a II a [ a a a a 1CLItICAL DEN!IIS•

V ' " •I 2 2 A A CLIN\OIC OC13 3 3 1 u K 1 8 COMMAN4LA-. 4 43 1 4 4 c m c ALA Of IE(T R

II 5 5 5 5 I 0 tIQ StAf F1 6 C . 6 o 6 [' "6 P AtlS INSTRUCTOR a

-'7 RESFAPCH POSITION

a 8 STUDENT1 9 9 9 9 9 9 9 9 if IF STUDENT Pt EASE INDICATE.

YEARS.OFEAEAR OF GRA UAVONFOM YEARS TO[ YEAR OF INUMBER OF GEN DENTPAN,, DENTAL PRACTICE DENTAL SCALAST PSFIXED PROSYER-S S-T SP.CLI PCS MOVESETXEDRPROS

TAy SCHOOLRE O

IMA-1 0 0 0 0 o3 0 a o" 0 o0' , 0 0 0o 0 PERIO U

" I, I , ,I , , 1 , 1 , 1 1 ORA\LSLIRG2 2 2 2 2 2 2 2 2 2 ENDO

3 3 6 13 '13 3AC l t GNN • o . o 6 6 6 6 G 6 WACOI:III(A a

P P/ K I. i-At If I

3. 4 e O' h /1 81) PAIH a

9 9II

ADITON AL 4TE N BDE O AVE: MRIITNRY DEGREESN ItP••YOUMA'f HAVE: MEDALS AN AGSYUHV:TRAINING: DEGREES:

PT OTiVF N OFFICER BASIC

'~~ I DE.' CRR A-tY Au'i MEDAL f OFFICER AD)VANCED SPA ~ i~SL;Pv OF-I AiM. 1)M SILVER STAR i C Et GS MD- q Mt3A A

-lFDU CA' ON ()I I M ;M BRONZE STARl ARMED FORCES MIsD MDu

,- ;i Al :,"LOM PURPLE IIEART STAFF COI LEGE MS aI()

i NI *..(MIER j \A9 COLLEGE Ne O1ILHI aR)• ~ ~~~~~ ,.!•l , l" DVANCED

-I _____ of OI -ER L i' IGE I

* * -AUXILLARY PERSONNEL

I N B O PERSONNEL'HO 2, O THESE PERSONNEL, WHO PERFORMS,WORK DIRECTLY WITH YOU THESE SELECTED PROCEDURFS7 a -

"tv MILITARY ,13 - A -,H~i1 0 1 2 3 i mZ

""S:,- AIS AIN IAKING IMPRESSIONS FOR STUDY CASTS 7 1 3 9

I Y; Al D , , :" I .- + REMOVING SUTURES AND DRESSINGS . ' _

F PlACING AMALGAM RF STORATIONS 2. I 3 IfI .', l . 1 ;+ ARVING AIM) FhII, IIlh AMAL(,AM RIFIT $C1h019 i 2 I

,• \!I'A'A. IP I) 1 I a 1 ILACING ANI) "INI, NII,(.,.OMP •SITU RFSI('•lAt N,- 2 3

CIVILIAN ADMINISTERING LOCAl ANESIHEFIC AGE NIS 1 2

, SIALANT APPLICATION 7 3 4

I0 . Y o 4 ORAL PROPIIYLAXIS""R•CALING 2 2 ,.p ,T A FAKING X PAYS 2

,vlnl 1- TING RI, ORD' 1

NUNNhram, D 04029DO N M

m" o DUTY/PRACTICE CHARACTERISTICS

1SINCE ENIERIiNG THE DENIAL. 2 INIAETH1 .1VVMN -SCORPS, HAVL YOU ALWAYg NUMBSf OF YEARS I L DE:NTISTS ARF HTREATED) PAPET'IITETN ArIENT I Ij"UR,

IN THE DENTAL I DENIAL CLINIC'jCORPS.

4 I

-III7 7

4 DURING THE PAbT YEAR, APPROM'MATELY HOW MANY HOURS PER WEEK DID YOU SPEND ,N THE f )LLOWING ACTIVI•I

V r'

15MIN sI .' 2q 5 : s o : .50 2,50

1PS WVEL1 HRSiWEEK iRS/W F R W NER( IAR; %zK I NF',- ',[K

30PIN rr~ ~ v-*2o ,*,I t , 1- - -: - - -; 'T - .. .. ..- I-T r4T.--. 1 -7-7'

45 MIN - 0 0 0, a0o

-~~ I~ 257 -1 10 1 ~ )

S2 2 2 2-

3 3 3 3 .3 3 A33.

r-4 --I,

INA -PA Ji.VA I ik L: -T ED

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I - -- TOTAL = 100% -

§ .\z\ •r 0 . ,

:o p o- I 00 0ý o,

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4 ~ US O2PNi OL *49

1 6 ON A TYPICAL DAY. HOW 7. WHAT PERCENTAGE E TA NUMBE ___

MANY OPERATORIES DID OF TREAYMENT %A . ... THE TOTAL NUMBER jYOu USF To HIFAf PATIENISý' PROVIDED USING o , OF DIFFERENT PA-

I THE TECHNIQUES I IENTS TREATEDOF "FOUR-HANDED" DURING A TYPICAL

-. DENTISTRY"' 2 WEEK.

3 3 3

6 0' 1 6'4 4 A. 4'

9 PLEASE INDICATE THE FOLLOWING REGARDING PATIENT CARE 10. EQUIPMENTJMATERIALS UTiLIZED IN YOURIItAT YOU PEiRSONNALLY PROVIDED DURING PAST YEAR: PRACTICE INCLUDES:

* rfl~OCC SM AN, S

_00 04. p_ _ .0PNOA.1(XR

AV'EEJ -AVIWF., -VW4 V/EE AV/EE r--l,}~m l., ,,-l -

-'- ~~Iny,'1 I -_-LT-]i L F• .__ L ~ i'. ADDITIONAL QUESTIONS•

•-,,{ (4 41o oj. NtJI.iO•OF S1Ai • 0 I 2 3 4 5+ •

I• t ' I IlI j DENTAL LICENSES t! ' 12 2 2 ;1•2 2' 5il',1[qO ~{'F' + •

II' if 2 [~SiNA[f OF ROVS*~~N~~C ANtiA ,0'O',

Sn;' CI- " 4I MBtIlOFPRorEs 0 f 2 5 ,10 2 m0 z

WEEKlA ARTICLES --.E AIEK VW E

6 4 6it'.' A. I• S'I .•• '. 'O.7 T'4AN I I

1 # 1 , '' 1 H !O I!LNrSSI T

o o C o , OF ! l CIC L24

' ._'. LABO.HATOI;Y PRCE . OURY CLIJIC LJ 1 2C. WORK SEI'JT 13. THE FOLLOWING PERTAINS TO mDUI:FS YOU (,OM'.4PLETE INCLUDES? TO ADL LICPAT.. WA.T.NG.TIM.S \

""'"..tCLLIDFS •,, IAl fIG LAI3OfA1 OIlY INCLUDES -

D2m1IEES I 2 2 0 1 2 3 -5

• " "16-- -

"-"~4 4 4t• 0~ N 2,P, 5• DE 10•¢_ 11 20 214 • " ;

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,, . ! I., ',]t- h\IV DARNTIICLS ,.1 tI' D It.!L-S / m -

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k.~ 6l 6AEI- 011 Y DAS 1.0bN .. P, 114~z -.40

I: i

o_1

2 O['• YOUI. CLINIC 1 2E HOW MANY 1 2F. THE AVtAGE I WEEKS V1 E.S Y CIC LAB

H,_AVI ARADNT01. TECHNCIAN TURN WOR SENT 13 THFOLOIG11TAN

S* LABORATOIY' WORKI iN TAROUND -LH PATIEN - TIMES"- T1l LAFS %0 C, I C 44 I CL D

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1!' • FOR 2 - 12 z 2 2j m

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{" 6¢ I- 6 I 6 :1__o I., Ii ,:

i : -il MARKS ON THIS FORM ,

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IhU .1 VL'IAI.7r7l7T i3 '•cE; 27'.,l~ u 12

ma 14. PLEASE PROVIDE THE FOLLOWING INFORMAT!O•N FOR EACH PROCEDURE,'TASE; LISIED BELOW

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APPENDIX D

ADDITIONAL ARMY DATA

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TABLE 7

PRIMARY DUTY ASSIGNMENT*

ALL DENT. 63A SPEC.P % %

CLINICAL DENTIST 69.9 W1.9 54.3

"iPROGRAM DIRECTOR 2.3 0.5 4.8

CLINIC OIC 14.4 6.3 25.2

COMMANDER 3.5 0.1 7.4

" ADL OFFICER 0.3 0.1 0.6

HO SIAFF 1.0 0.4 1.9

AHS INTRUCTOR 0.3 0.2 0.5

RESEARCH POSITION 0.8 0.2 1.4

OTHER 7.4 10.4 3.7

TABLE 8

ADDITIONAL DUTIES**

ALL DENT. 63A SPEC

PREV DEN OFF 16.0 21.6 8.6

PT OFF 5.2 5.8 4.4

DEP CDR 5.1 1.6 9.8

SUPPLY OFF 12.1 13.8 9.8

EDUCATION OFF 10.8 8.1 14.3

PREC METALS OFF 15.7 13.5 18.7

MENTOR 13.4 1.8 28.7

OTHER DUTIES 78.1 80.9 74.3

• Percentage of responses listed. Respondents are assignedone primary duty which is exclusive of other duties, thus total

of resonses equal 100%.

•* Percentage of cases listed. Respondents may be assignedseveral additional duties; total o* responses may exceed 100%.

103

TABLE 9

MEDALS AND BADGES

ALL 63A SPECIAL-DENTISTS DENTAL OFF. ISTS

ARMY ACH MEDAL 19.73 23.0 16.27

ARCOM 71.29 58.6 84.54

MSM 31.93 9.2 55.22

LOM 0.29 0.0 0.60

EFMB 27.15 35.4 18.67

SILVER STAR 1.37 0.0 0.00

p BRONZE STAR 10.16 3.8 16.67

PURPLF ,iEAcT 0.98 0.4 1.61

OTHER 39.65 35.2 44.38

TABLE 10

* MILITARY TRAINING

ALL ,A SPECIAL-DENTISTS DENTAL OFF. ISTS

OFFICER BASIC 90.52 95.2 83.20

OFFICER ADVANCED 47.38 27.7 77.41

C&GS 6.29 1.5 13.51

AF STAFF COLLEGE 0.30 0.0 0.77

SOTHER TRAINING 8.79 8.0 10.04

0104

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TABLE 12

WHO SHOULD PERFORM SELECTED PROCEDURES?

DATA GIVEN IN PERCENTAGE OF RESPONDENTS

RESPONSES FOR ALL DENTISTS

DDS DTA ASST NOT DONE

STUDY CAST IMPRRESS 54.9 10.7 34.4 8.8

* A REM SUTURES/DRESS 79.0 4.7 16.3 12.0

PLACE AMALGAM REST. 75.8 24.0 0.2 16.0

CARVE/FINISH AMALGAM 75.8 24.1 0.1 16.1

.- PLACE/FINISH COMPOSITE 75.5 23.4 1.1 16.0

"ADM. LOCAL ANESTH. 100.0 0.0 0.0 5.5

SEALANT APPLICATION 75.4 21.6 3.0 47.7

ORAL HYGIENE INSTR 50.0 25.9 24.1 1.5

ORAL PROPHYLAXIS 32.0 59.9 8.1 24.0

l• SCALING 51.4 46.1 2.5 19.1

TAKING X-RAYS 15.6 11.2 73.2 20.9

- COMPLETING RECORDS 66.7 11.0 22.7 0.5

10

•A:j

{.v5- '•,1

10

, ,

TABLE 13

WHO SHOULD PERFORM SELECTED PROCEDURES?

DATA GIVEN IN PERCENTAGE OF RESPONDENTS

RESPONSES FOR GENERAL DENTISTS

DDS DTA ASSN NOT DONE

STUDY CAST IMPRRESS 54.6 12.2 33.2 7.4

REM SUTURES/DRESS 83.0 4.0 13.0 6.7

i• PLACE AMALGAM REST. 72.6 27.3 0.1 4.7

-, CARVE/FINISH AMALGAM 72.8 27.1 0.1 4.7

PLACE/FINISH COMPOSITE 73.0 27.0 0.0 4.9

"ADM. LOCAL ANESTH. 100.0 0.0 0.0 0.3

"- SEALANT APPLICATION 75.7 22.1 2.2 39.9S.

ORAL HYGIENE INSTR 49.5 30.8 19,6 0.9

ORAL PROPHYLAXIS 28.5 67.1 4.4 17.9

SCALING 48.3 50.9 0.8 13.2

--- TAKING X-RAYS 15.7 11.1 73.3 18.2

COMPLETING RECORDS 68.6 12.6 18.8 0.4

q .

* 0

S~107

TABLE 14

WHO SHOULD PERFORM SELECTED PROCEDURES?

DATA GIVEN IN PERCENTAGE OF RESPONDENTS

RESPONSES FOR SPECIALISTS

• DDS DTA ASSN NOT DONE

STUDY CAST IMPRRESS 55.0 8.4 36.5 10.8

REM SUTURES/DRESS 71.8 5.9 22.2 19.9

PLACE AMALGAM REST. 84.1 15.3 0.6 35.9

CARVE/FINISH AMALGAM 83.4 16.3 0.3 36.1

PLACE/FINISH COMPOSITE 85.2 14.8 0.0 36.1

ADM. LOCAL ANESTH. 00.0 0.0 0.0 13.8

SEALANT APPLICATION 74.6 20.4 5.0 60.3

ORAL HYGIENE INSTR 50.6 17.8 31.6 2.3

ORAL PROPHYLAXIS 38.7 45.9 15.5 33.6

SCALING 57.4 36.6 5.9 28.5

TAKING X-RAYS 15.4 11.6 72.9 25.2

COMPLETING RECORDS 62.5 8.7 28.8 0.6

N.

* *

SV10

TABLE 15

MEAN TIME ESTIMATES AND

DOLLAR VALUE OF SELECTED PROCEDURES

ALL DENTISTS

i timeminutes value

ORAL EXAM WO X-RAYS 11.07 21.63

ONE-SURFACE AMALGAM 18.10 21.83

TWO-SURFACE AMALGAM 25.48 32.02

THREE-SURFACE AMALGAM 31.04 40.97

' SINGLE FULL GOLD CROWN 120.83 256.76

ANTERIOR ROOT CANAL 78.86 144.98q

UPPER ACRYLIC DENTURE 218.02 320.26

SINGLE TOOTH EXTRACTION 24.29 29.69

II

i,

C>

* ' 109'°

TABLE 16

MEAN TIME ESTIMATES AND

DOLLAR VALUE OF SELECTED PROCEDURES

GENERAL DENT.

timeminutes value

ORAL EXAM WO X-RAYS 10.0 18.84

ONE-SURFACE AMALGAM 17.6 21.54

TWO-SURFACE AMALGAM 25.4 31.71

. THREE-SURFACE AMALGAM 31.1 40.76

u. SINGLE FULL GOLD CROWN 119.8 265.07

ANTERIOR ROOT CANAL 79.0 148.03

UPPER ACRYLIC DENTURE 206.3 326.52

- SINGLE TOOTH EXTRACTION 23.9 27.97

11'.

...

9"-

11

--

TABLE 17

MEAN TIME ESTIMATES AND

DOLLAR VALUE OF SELECTED PROCEDURES

SPECIALISTS

timeminutes value

ORAL EXAM WO X-RAYS 12.0 22.86

ONE-SURFACE AMALGAM 17.0 21.00

. ' TWO-SURFACE AMALGAM 29.0 S2.70

THREE-SURFACE AMALGAM 31.4 42.09

SINGLE FULL GOLD CROWN 115.7 267.69

ANTERIOR ROOT CANAL 63.4 150.71

UPPER ACRYLIC DENTURE 194.0 350.24

SINGLE TOOTH EXTRACTION 20.4 26.54

40

-V.-

* 0

-2

o-2

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0 1

TABLE 18

PATIENT AGES

10 YEARS OR YOUNGER 7.5

10 TO 15 8.1

15 TO 25 38.9

25 TO 50 34.4

"50 ABOVE 15.0

• -TABLE 19

PATIENT STATUS

ACTIVE DUTY ARMY 46.09

OTHER MILITARY 4.25

ADULT DEPENDENTS 18.12

"CHILD DEPENDENTS 13.00

RETIRED 14.08

J OTHER 3.26

HAND I CAPPED:PHYSICALLY OR MENTALLY 2.63

0"- -. -V

.- ?,

4

* 6.

:• 112

0• . . . . . . . . . . . .

TABLE 20

LABORATORY PROCEDURES COMPLETED BY DENTISTS

ALL 6'A SPECIAL-

DENTISTS OFFICERS ISTSmean mean mean

TRIM DIES 74.5 86.5 52.9

ARTICULATE MDLS 58.0 64.2 46.8

- TRAY FAB. 24.6 29.8 15.0

OCCLUSAL RIMS 14.0 17.8 7.1

SET "EETH 15.1 15.3 14.7

POLISH DENT. 26.2 29.4 20.5

SWAX-UPS 13.9 14.6 12.6

METAL FINISH 28.2 32.5 20.5

P FORC. APPL 5.4 4.9 6.3

STAIN GLAZE 48.7 53.1 40.8

OTHER 48.6 42.5 59.7

* 0

r. .•

,--

', %,•113

TABLE 21

CLINIC LABORATORY SUPPORT

ALL 63A SPECIAL-DENTISTS OFFICERS ISTS

mean mean mean

NO CLINIC LAB 13.1 14.9 10.2

DENTURES 55.4 57.9 51.1

CROWNS 52.2 54.2 48.9

PORCELAIN VENEER CROWNS 27.4 26.0 29.6

N CAST PARTIAL DENTURES 8.2 8.2 8.2

"CAST DOWEL/CORE 47.4 48.1 46.0

SPACE RETAINERS 45.4 44.6 46.5

OTHER 49.5 42.0 62.2

.114

**.

* *

S~1140.

TABLE 22

AREA DENTAL LABORATORY SUPPORT

ALL 63A SPECIAL-

DENTISTS OFFICERS ISTS

mean mean mean

DENTURES 30.1 31.2 28.2

CROWNS 63.5 68.2 54.6

PORCELAIN VENEER CROWNS 78.5 82.0 71.6

CAST PARTIAL DENTURES 79.9 82.2 75.3

CAST DOWEL/CORE 22.1 22.9 20.7

SPACE RETAINERS 17.4 17.4 17.5

OTHER 28.0 23.2 37.1

AV LAB TURN-AROUND TIME (weeks) 6. 3'

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jf APPENDIX F

2' PROCEDURES NOT PERFORMED

•. 119

YI.

*• Procedures Not Performed

2420 GOLD FOIL II 5915 NOSE PROS"3980 ENDOSSEOUS IMP 5935 FACIAL PROSTHES4372 BICUSPIDIZATION 5940 IMPLANTS5170 COMP DTR AML OC 5950 INCLINE PLANE5207 PRECISN ATTACH 5955 MND GUIDE PLN5270 AMALG OCCLUSALS 5960 PALATAL LIFT5812 DUPE MAX OVERDT 5970 OBTURATOR5813 DUPE MND OVRDT 6170 INTRACORONAL RT5816 OVERDTR MAX MTL 7265 CLEFT LIP REPAIR5817 OVERDTR MND MTL 7520 BIOPSY

V 5825 OVERDTR ATTACHM 7880 ARTHROGRAPHY5864 OVERDTR PTR MX 8212 HABIT MOUTH BRE5866 OVRDTR IM MX P 9944 RAD NDL CARER

,t-

lL;• 120

> • APPENDIX Gi'• INFREQUENTLY PERFORMED PROCEDURES

3

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•. 121

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DISTRIBUTION:

Defense Technical Information Center (DTIC) (2)

HQDA (DASG-DC) (1)

A. Director, Joint Medical Library, Offices of The Surgeons General, USA/USAF,The Pentagon, Rm 1B-473, Washington, DC 20310 (1)

HQ USA HSC (ATTN: HSDC) (1); (ATTN: HSDS) (1)

HQ 7th MEDCOM (ATTN: AEMDC) (1); (ATTN: AEMDS) (1)

* i Commander, 10th Medical Detachment (DS) (1)

HQDA (DASG-HCD-S) (1)

AHS USA, Stimson Library (1)

Defense Logistics Studies Information Exchange, USA Logistic ManagementCenter, Fort Lee, VA 23801 (1)

1.:: Dental Science Division, HSHA-IDS, Building 2841, Fort Sam Houston, TX 78234S~(1)

CDR, USAIDR WRAMC, ATTN: SGRD-UDZ, Building 40, Washington, DC 20307 (1)

1124

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