Department  of Health  and Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
STATE  DENTAL  BOARDS  AND 
DENTAL  DISCIPLINE 
AUGUST  1993  OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department  of Health and Human Services (HHS) 
programs as well as the health and welfare of beneficiaries served by those programs.  This 
statutory mission is carried out through a nationwide network of audits, investigations, and 
inspections conducted by three OIG operating components:  the Office of Audit Services, the 
Office of Investigations, and the Office of Evaluation and Inspections.  The OIG also informs 
the Secretary of HHS of program and management problems and recommends courses to 
correct them. 
OFFICE OF AUDIT  SERVICES 
The OIGS Office of Audit Services (OAS) provides all auditing services for HHS, either by 
conducting audits with its own audit resources or by overseeing audit work done by others. 
Audits examine the performance of HHS programs and/or its grantees and contractors in 
carrying out their respective responsibilities and are intended to provide independent 
assessments of HHS programs and operations in order to reduce waste, abuse, and 
mismanagement and to promote economy and efficiency throughout the Department. 
OFFICE OF INVESTIGATIONS 
The OIGSOffice of Investigations (01) conducts criminal, civil,and administrative 
investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries and of 
unjust enrichment by providers.  The investigative efforts of 01 lead to criminal convictions, 
administrative sanctions, or civil money penalties.  The 01 also oversees State Medicaid fraud 
control units which investigate and prosecute fraud and patient abuse in the Medicaid program. 
OFFICE OF EVALUATION  AND  INSPECIIONS 
The OIGSOffice of Evaluation and Inspections (OEI) conducts short-term management and 
program evaluations (called inspections) that focus on issues of concern to the Department, 
the Congress, and the public.  The findings and recommendations contained in these inspection 
reports generate rapid, accurate, and up-to-date information on the efficiency, vulnerability, 
and effectiveness of departmental  programs. 
This report was prepared under the direction of Mark R. Yessian, Ph.D., Regional Inspector 
General, and Martha B. Kvaal, Deputy Regional Inspector General, Boston Region, Office of 
Evaluation and Inspections.  Participating in this project were the following people: 
Boston  Headquarters 
Barry McCoy, Lead Analyst  Alan S. Levine 
Theodore  Wall, Program Analyst 
For additional copies of this report, please contact the Boston regional office at 617/565-1050.  Department  of Health  and Human  Services 
OFFICE  OF 
NSPECTOR  GENERAL 
STATE  DENTAL  BOARDS  AND 
DENTAL  DISCIPLINE 
AUGUST  1993  0EI-01-92-O0821  EXECUTIVE  SUMMARY

PURPOSE 
To  examine  the  capacity  of State  dental  boards  to carry  out  their  disciplinary 
responsibilities. 
BACKGROUND 
In a recent  inspection,  The Licensure  of Out-of-State  Dentists  (OEI-01-92-00820),  we 
found  that  many  State  dental  board  officials had  serious  concerns  about  the  capacity 
of the  boards  to identify  and  respond  to incompetent  and/or  unprofessional  dentists. 
They  cited  these  concerns  as a major  basis for requiring  out-of-State  dentists  to pass  a 
clinical  licensure  exam  before  granting  them  a license. 
In this follow-up  report,  we identify  and  review  indicators  of boards  capacity  to carry 
out  their  disciplinary  responsibilities.  We  draw  on data  collected  from  a survey of the 
boards  as part  of the  above-noted  inspection  and  on data  available  from  published 
sources. 
FINDINGS 
THERE  ARE  STRONG  BASES  FOR  QUESTIONING  THE  CAPACITY  OF 
STATE  DENTAL  BOARDS  TO  CARRY  OUT  THEIR  DISCIPLINARY 
RESPONSIBILITIES. 
They  lack  comprehensive  reporting  laws which  can help  them  identi&  dentists 
warranting  investigation. 
.	 Twenty-nine  of 48 reporting  boards  indicate  that  their  States  do not  have 
laws mandating  other  parties  to report  to the  board  a dentist  who may 
have  violated  the  State  dental  practice  act.  In contrast,  47 States  have 
mandated  reporting  laws for physicians. 
.	 Only  14 of the  48 boards  indicate  that  their  States  require  dentists  to 
report  to the  board  another  dentist  who may have  violated  the  State 
practice  act.  Thirty-one  States  have  such laws applying  to physicians. 
They  make  limited  use  of disciplirmy  action  clearinghouses. 
.	 In  1992, only 23 of 48 reporting  boards  requested  information  from 
the  clearinghouse  maintained  by the  American  Association  of Dental 
Examiners  and  only 19 from  the  one  maintained  by the  National 
Practitioner  Data  Bank.  Failure  to obtain  such information  can 
i  deprive  boards  of knowledge  about  prior  actions  involving  dentists 
under  investigation. 
They  discipline  dentists  to widely varying  degrees  and  at  a level  somewhat  less than 
that  of State  medical  boards. 
.	 During  the  September  1, 1990 to August  31, 1992 period,  dental  board 
disciplinary  actions  per  1,000 active  dentists  ranged  from  lows of O in 
Connecticut,  Delaware,  Kentucky,  Hawaii,  and  Wyoming  to highs of 23.2 
in Oregon,  15.0 in Alaska,  19.2 in Missouri,  13.5 in Maine,  and  12.0 in 
Iowa. 
The  median  and  average  rates  of disciplinary  actions  per  1,000 active 
dentists  taken  by dental  boards  during  this period  was 6.41 and  7.0.  The 
comparable  figures  for medical  boards  were  6.65 and  8.94.  Although 
this differential  is not  extensive,  it is important  to recognize  that  dental 
boards  may be  more  vital  quality  assurance  bodies  for dentists  than 
medical  boards  are  for physicians.  This  is because  dentists  are  much 
more  likely to practice  alone  and  much  less likely to be  subject  to 
oversight  by other  external  bodies,  such  as hospitals  or health 
maintenance  organizations. 
They  have  insufficient  resources  to devote  to investigations,  particularly  of complex 
cases  involving  the  quality  of dental  care  rendered. 
.	 The  American  Association  of Dental  Examiners,  the  association  of State 
dental  boards,  cites  the lack of sufficient  funding  as the  principle  reason 
for enforcement  difficulties. 
.	 Eighteen  of 24 boards  reporting  that  they  have  their  own investigators 
indicate  that  caseloads  have  increased  since  1989, but  only 5 state  that 
staffing  levels have  increased  during  the  same  period. 
.	 Twenty-three  of 48 reporting  boards  indicate  that  they  do not  maintain 
an in-house  computerized  file incorporating  data  on prior  complaints 
against  a dentist.  Thirty-one  of them  state  the  same  in regard  to  data  on 
settled  malpractice  claims. 
CONCLUSION 
The  information  presented  in this report  reinforces  the  concerns  of many  State  dental 
board  officials  about  the  capacity  of the  boards  to carry  out  their  disciplinary 
responsibilities.  But  the  significance  of the  information  goes beyond  whether  or not 
out-of-State  dentists  should  be  licensed  by any given board.  It suggests  that  many 
boards  may not  be  providing  adequate  protection  to the  consumers  of dental  services 
ii  and  that  they  and  the  State  governments  of which they  are  a part  would  find it 
constructive  to focus  on ways in which  they  could  improve  the  capacity  of the  boards. 
The  PHS,  through  the  Agency  for Health  Care  Policy and  Research  or the  Bureau  of 
Health  Professions,  could  facilitate  State  efforts  to improve  the  capacity  of their  dental 
boards  by extending  financial  support  for the  development  of a self-assessment 
instrument  for the  boards.  The  PHS  has  supported  a similar  effort  for State  medical 
boards,  with notable  success. 
... 
111  TABLE  OF  CONTENTS

PAGE

EXECUTIVE  SUMMARY

INTRODUCTION.  . . . . . . . . . . . . . . . .  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1

FINDINGS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...4

  Renewal  Fee  Income  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...4


Consumer  Membership  on Dental  Boards  . . . . . . . . . . . . . . . . . . . . . . . . . ...6


State  Mandatory  Reporting  Laws  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..7


Investigative  Staffing  Levels  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8


Computerized  Information  Systems  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...9


Disciplinary  Action  Clearinghouses  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  10


Disciplinary  Actions.  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  11

CONCLUSION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  12

APPENDIX

k  Endnotes  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..A-l  INTRODUCTION

PURPOSE 
To  examine  the  capacity  of State  dental  boards  to carry  out  their  disciplinary 
responsibilities. 
BACKGROUND 
Prior  Reports 
In an August  1988 report,  State  Licensure  and  Discipline  of Dentists  (OAI-Ol-88-
00580), we raised  concerns  about  how well State  dental  boards  were  carrying  out  their 
disciplinary  responsibilities.  In an August  1993 report,  The Licensure  of Out-of-State 
Dentists  (OEI-01-92-00820),  we reported  that  many  board  officials  themselves  were 
raising  such concerns  and  citing them  as a major  basis  for requiring  out-of-State 
dentists  to pass  a clinical  examination  as a condition  of licensure.  These  board 
officials  expressed  serious  reservations  about  the  capacity  and  readiness  of many 
boards  to identify  and  then  respond  to incompetent  and/or  unprofessional  dentists. 
Federal  Interest 
Given  the  primacy  of the  State  role  in licensing  and  disciplining  dentists,  it is 
important  to establish  the  bases  for the  Federal  interest  in the-capacity  of State  dental 
boards.  The  most  direct  basis is the  Medicaid  program,  under  which  the  Federal 
government  now contributes  about  $1 billion  a year  for dental  services.l  It looks  to 
the  boards  to provide  a vital front  line of protection  for the  recipients  of those 
semices.  It relies  upon  them  to see that  dentists  meet  the  minimum  necessary 
qualifications  to practice  dentistry  and  to take  disciplina~  action  against  them  when 
their  conduct  and/or  practice  warrant  it. 
But  the  Federal  interest  in boards  also rests  on the  protection  they  provide  to all 
consumers  of dental  services,  who, from  various  payment  sources,  are  generating 
annual  expenditures  of close to $40 billionz for services  performed  by about  145,00 
dentists.3  To  the  extent  that  dental  boards  carry  out  their  responsibilities  effectively, 
they  contribute  to the  capacity  of the  dental  profession  to respond  effectively  to oral 
diseases.  The  U.S. Public  Health  Service  (PHS)  has identified  oral  diseases  as being 
among  the  most  prominent  in the  United  States4 and  has  set forth  many  specific 
objectives  to reduce  their  incidence  by the  year  2000.5  These  objectives  could 
become  of even  greater  concern  to the  Federal  government  if some  dental  coverage  is 
included  as a core  benefit  under  a reformed  national  health  care  system. 
Over  the  years,  the  PHS,  through  the  Bureau  of Health  Professions,  has  taken  a 
number  of actions  to contribute  to the  development  of dental  (and  other  health  care) 
boards.  In  1984, it funded  the  Council  on Licensure,  Enforcement  and  Regulation  of 
1  the  Council  of State  Governments  to prepare  a composite  State-by-State  information

system  on dental  and  other  health  care  boards.  In  1989, it funded  the  American

Association  of Dental  Examiners  (AADE),  the  association  of State  dental  boards,  to

help  it convert  its disciplinary  action  clearinghouse  from  a manual  to a computerized

system.  And, just  recently,  in 1993, it once  again  funded  AADE,  this time  to facilitate

its efforts  to develop  criteria  and  mechanisms  that  State  dental  boards  can  use when

assessing  the  continued  competency  of dentists.

Finally,  it is also important  to recognize  that  PHS  has  an ongoing  interest  in State

dental  boards  because  of its responsibilities  for managing  the  National  Practitioner

Data  Bank  (NPDB)  established  by the  Health  Care  Quality  Improvement  Act  of 1986.

Intended  by Congress  to facilitate  improved  credentialing  activities  by health  care

institutions  and  licensing  bodies,  the  NPDP  serves  as a clearinghouse  of information

on disciplinary  and  adverse  actions  taken  against  health  care  practitioners.  Among

health  care  licensing  boards,  only medical  and  dental  boards  are  required  to report  all

their  disciplinary  actions  to the  NPDP.

METHODO~GY

In this report,  we draw  on data  collected  from  our  1992 survey of State  dental  boards.

That  survey was conducted  primarily  for our inspection  on out-of-State  dentists  and

focused  on questions  addressing  that  topic.  It included,  however,  a number  of

questions  addressing  the  disciplinary  capacities  of the  State  boards.  In addition  to

these  data  elements,  we draw  on data  available  in many  published  reports  of the

American  Association  of Dental  Examiners  (AADE),  the  American  Dental

Association  (ADA),  The  Federation  of State  Medical  Boards  (FSMB),  the  American

Medical  Association  (AMA),  and  the  National  Practitioner  Data  Bank  (NPDB).

We  organize  the  report  around  seven  key indicators  of boards  capacity  to carry  out

their  disciplinary  responsibilities.  These  are  not  the  only such indicators,  but  they  are

ones  which we have  found  pertinent  in our work  over  the  past  seven  yearsG and  in

our  review  of the  literature  on the  licensure  and  discipline  of the  health  care

occupations.7  They  are  also indicators  for which we can present  current  and  reliable

data.  In each  case, we present  a brief  statement  indicating  why the  indicator  is

pertinent  to a boards  capacity  to carry  out  its disciplinary  responsibilities,  a figure

revealing  the  key data,  and  brief  explanatory  text.  Data  was provided  for the  50

States  and  the  District  of Columbia,  hereafter  referred  to as States.

To  facilitate  interpretations  of the  data,  we present  them,  where  possible,  in a manner

that  allows for comparative  assessments.  We  do this primarily  by presenting  trend

data  for recent  years.  The  actual  time  periods  we use vary because  of inconsistencies

in the  data  available.

We  also allow for some  comparative  assessment  by presenting  parallel  data,  where

available,  for State  medical  boards.  Such boards  ha;e  the  sa;;  basic  responsibilities

as dental  boards.  It is important  to take  into  account,  however,  that  dental  boards

2  may well be  a more  vital  quality  assurance  overseer  for dentists  than  medical  boards 
are  for physicians.  This is because  dentists  are  less likely to be  subject  to oversight  by 
other  bodies,  such as hospitals,  health  maintenance  organizations,  Medicare-funded 
Peer  Review  Organizations,  and  insurers.8 
We  conducted  this study in accordance  with the  Quality Standards for Inspections 
issued  by the  Presidents  Council  on Integrity  and  Efficiency. 
3
 FINDINGS

THERE  ARE  STRONG  BASES  FOR  QUESTIONING  THE  CAPACITY  OF 
STATE  DENTAL  BOARDS  TO  CARRY  OUT  THEIR  DISCIPLINARY 
RESPONSIBILITIES. 
There  may be  individual  boards  that  have  adequate  capacity  to carry  out  their 
disciplinary  responsibilities  and  that  are  performing  effectively  in this regard.  But  the 
information  we present  on the  following  seven  indicators  raises  serious  questions  about 
the  disciplinary  capacity  of most  boards.  These  data  support  the  reservations  that 
many  State  board  officials  themselves  expressed  to us during  our  inquiry  on the 
licensure  of out-of-State  dentists. 
Renewal  Fee Income 
FIGURE  1: ANNUAL  LICENSE  RENEWAL  FEES  FOR 
DENTISTS  AND  PHYSICIANS,  1985  AND  1992 
1985 
MEDIAN

 
FEE  ......  DENTISTS

AVERAGE

FEE

1992

MEDIAN 
FEE 
AVERAGE 
FEE 
do  $25  $40  $75  $100  $125 
ANNUAL FEE 
souroes Fordentists-CouncilofStateGovernmentsS,tatsRe@atmnQftileliafdthQca@Qns  and 
&afQ&xw  lQ4%8&Maroh1987andOIGtelephonesurvey,April1993. Forphysldans-American 
Madical  AssociationL,B MeslkaLlbnaum ~  1985/19S6 and 1993 editions. N -51  Statsa. 
4
 The  median  renewal  fee  of dental  boards  has increased  from  $40 to $75 between  1985 
and  1992, but  it still lags that  of medical  boards,  which increased  from  $50 to $100 
during  the  same  period  (figure  1). In California,  the  State  with the  largest  number  of 
licensed  dentists,  the  1992 dental  board  renewal  fee was $120, compared  with  $250 for 
the  medical  board.  In New York,  the  State  with the  second  largest  number  of licensed 
dentists,  the  comparable  fees were  $70 and  $165. 
Aside  from  the  level  of the  fees, it is important  to recognize  that  the  fee  income  often 
is not  reserved  exclusively for the  use  of the  dental  board.  This was the  case  for  17 of 
the  48 States  responding  to the  relevant  question  in our  survey. 
Thus,  it appears  quite  possible  that  many  boards  are  left with insufficient  resources  to 
do their  investigatory  work.  The  American  Association  of Dental  Examiners,  the 
association  of State  dental  boards,  acknowledged  that  such  a deficiency  does,  in fact, 
exist when  in response  to our  prior  report  on out-of-State  dentists,  it commented  that 
the lack  of sufficient  funding  is the  principle  reason  for enforcement  difficulties. 
5
 Consumer  Membership  on Dental  Boards
FIGURE  2: PUBLIC MEMBERSHIP  OF STATE  DENTAL

AND MEDICAL  BOARDS,  1988 AND 1991

1988 
DENTAL 
BOARDS  Z  10% OR LESS 
 
11-20% 
 
MEDICAL  MORETHAN20% 
BOARDS 
1991 
DENTAL 
BOARDS 
MEDICAL 
BOARDS 
A

10 20 30 &  50 
NUMBER OF DENTAtJMEDICAL BOARDS 
Sourcw  For dentists-AmericanAssociationof Dental Examiners,CompQMQ,1989 and 1992 
adiions. Forphysicians-FederationofStateMedicalBoards,Fxchange,1989-1990  and 
1992-1993  editions. N -51  States.  Note -we include only public members with full 
voting privileges. 
In  1989, a broadly  based  task  force  of The  Federation  of State  Medical  Boards  issued 
an important  report  entitled  Elements  of a Modern  State  Medical  Board:  A 
Proposal.  Although  it focuses  on medical  boards,  it offers  many  suggestions 
concerning  board  membership,  structure,  and  operation  that  can  also be  highly 
instructive  to dental  boards.  One  of those  suggestions  is that  public  or consumer 
members  should  constitute  25 percent  of a boards  membership.9 
Even  this modest  benchmark  is one  which most  medical  and  dental  boards  fall short 
of meeting  (figure  2). In fact,  15 dental  boards  have  10 percent  or fewer  consumer 
members  and  38 have  20 percent  or fewer;  the  comparable  numbers  for medical 
boards  are  8 and  32. 
6
 State Mandatoy  Repo&g  Luws
o  10  20 30 4)  5b 
NUMBER  OF STATES 
Sources  Fordentists-OIGmailsurvey,Fall1992.  Forphysicians-l%e FederationofState 
Medioal Boards, ExckngQ,1992  -1993 sdition. N =43  States. 
Among  48 States  for which we have  comparative  information,  47 have  mandated 
reporting  laws for physicians,  but  only 19 have  them  for dentists  (figure  3).  Only  14 of 
these  States  require  individual  dentists  to report  to the  board  other  dentists  who they 
believe  may be  acting  in an unprofessional  manner  or delivering  substandard  dental 
care.  Even  fewer  States  require  hospitals  (13) or professional  associations  (7) to 
report. 
Given  the  relative  lack of reporting  laws and  the  fact  that  the  great  majority  of 
dentists  practice  alone,  it can be  quite  difficult  for State  dental  boards  to identify 
dentists  responsible  for poor  practice  or some  wrongdoing.  More  so than  State 
medical  boards,  they  are  dependent  on referrals  made  by individual  consumers.  Investigative  Sta~g  Levei?s
FIGURE 4:  CHANGES IN INVESTIGATIVE CASELOADS 
AND INVESTIGATOR  STAFFING  LEVELS AT STATE 
DENTAL BOARDS, FROM 1989 TO 1992 
0 
II 
LOWER  CASELOADS 
w 
a 
z 
<  STAFFING 
x 
u 
,,  L  6 
a 
5 
HIGHER 
I ,
0 
5  10  15  20  25 
NUMBEROFBOARDS 
Source: OIGmail survey, Fall 1992.  N-24Statedental  boardsrepotting theyhaveinvestigatm 
on their own staffs. 
In response  to our  survey of the  State  dental  boards,  24 reported  that  they have  their 
own investigators  to follow up  on complaints  or referrals  received  by the  board 
(figure  4).  Among  these  24, 18 indicated  that  their  caseload  increased  during  the  prior 
three  years,  but  only 5 stated  that  their  investigative  staffing  level  had  also increased. 
Such  a disparity  contributes  to higher  caseloads  per  investigator  and  more  constricted 
investigatory  efforts. 
Whether  the  boards  that  rely on investigators  in a parent  department  are  experiencing 
a similar  strain  in staffing  support  is not  clear  from  our  survey.  It is more  difficult  to 
assess investigative  staffing  trends  for these  boards  because  the  investigators  often 
serve  boards  besides  the  dental  board. 
8
 Computerized  Information  Systems
FIGURE  5:  TYPES  OF COMPUTERIZED  INFORMATION 
MAINTAINED  BY STATE  DENTAL  BOARDS  OR THEIR 
PARENTIDEPARTMENTS  ON  LICENSED  DENTISTS,  1992 
j  PRIOR 131SCIPLINARYACTIC)NS  \34 
PRIOR COMPLAINTS  25 
i 
MALPRACTICE CUdMS  ,7 
{ SEITLED 
1=
ACTIONS  Y  7 
OTHER  ST  TES
I 
o	 10 20  30  40 
NUMBER  OF BOARDS/PARENT  DEPARTMENTS 
Sourcxx OIG mail survey, Fall 1992.  N -44  States report having computerized informationon licensed 
dentiat~ 43 States  responded  to the survey question. 
Most  dental  boards  (34 of 48 reporting)  can turn  to a computerized  file that  they  or 
their  parent  department  maintains  to determine  if they  have  taken  prior  disciplinary 
action  against  that  dentist  (figure  5),  But for other  types  of information  pertinent  to 
an investigation,  fewer  boards  are  likely to have  this opportunity.  Twenty-five  of the 
48 can look  to an in-house  computerized  file to determine  if any prior  complaints  have 
been  lodged  against  the  dentist,  17 to learn  if there  have  been  settled  malpractice 
claims  involving the  dentist,  and  only 7 to find out  if any other  State  has taken 
disciplinary  action  against  the  dentist. 
With  some  effort,  such information  can almost  always be  obtained  by the  inquiring 
board.  But  its lack  of ready  availability  adds  to the  cost and  time  of an investigation 
and  ultimately  impedes  the  effectiveness  of a board. 
9  FIGURE  6:  STATE  DENTAL  BOARDS  USE OF DISCIPLINARY 
ACTION CLEARINGHOUSES, 1992 
REVIEWED  THE MONTHLY AADE DISCIPUNARY  REPORTS  FOR 
37 
DENTISTS  UCENSED  IN STATE 
REQUESTED  INFORMATION  FROM AADE 
23 
FOR NAMED  DENTISTS 
I 
REQUESTED  INFORMATION  FROM 
19
NPDB FOR NAMED DENTISTS 
t 
10 20  30  40 
NUMBER OF BOARDS 
Sourw  OIGmailsurvey,Fall1992. N-43  States.(Eachstatedidnotrespondtoeachofthethree 
questionsposed.)AADE- AmericanAssociation01DentalExaminers.NPDB- NationalPrac$itloner 
Data Bank. 
Nearly  all of the  dental  boards  that  addressed  the  pertinent  question  in our  survey 
(37 of 41), reported  that  they  reviewed  the  monthly  reports  that  the  AADE  sends 
them  on dentists  licensed  in their  States  (figure  6).  But  during  the  past  year,  only 23 
indicated  that  they  made  any name  requests  of the  AADE  and  only 19 of the  NPDP. 
The  $6 ($10 for paper  queries)  accessing  fee  charged  by the  NPDP  may have  some 
effect  in limiting  the  boards  readiness  to make  name  requests  of it.  Why they  may 
also be  disinclined  to make  such inquiry  of the  AADE  clearinghouse,  which  is 
available  free  of cost for the  first  100 queries  in a year,  is  less clear. 
10  Dkciplinq  Actions
FIGURE  7: RATE OF DISCIPLINARY  ACTIONS  BY STATE 
DENTAL  AND  MEDICAL  BOARDS,  9/1/90  - 8/31/92 
b  lb  20 4)  4) 
NUMBER OF ACTIONS  PER 1000 ACTIVE  PRACTITIONERS 
Scurces  For denflsts -National Practltkner  Datn Bank Ilcenaum acilons reported by Sfata dental 
boards for 9/1/90 -3/31/92  and lhe American Dental AsaodaUon, IWl,  1992 RktdbWm  9f Ran!&la 
imihaL!niied Si@eshy  E@c)naod  S!ata.  Forpt@Asms-NalPUroancaW onerDataBank,Bncaew  e
acdons mportad by Stefe medkai boards for9/1/90.  6/31/92  and The Federatbn  of S@ta Medbl 
Boards, ~  1992-1993  adltlon. N - SOStataa. 
The  number  of disciplinary  actions  taken  by dental  boards  during  the  September  1, 
1990 to August  31, 1992 period  varied  greatly;  at one  extreme  five boards  took  no 
such actions  and  at the  other  5 took  12 or more.10  Overall,  the  median  was 6.41 and 
the  average  7.0.  This  compares  with 6.65 and  8.94 for medical  boards  (figure  7). 
Thus  dentists  were  somewhat  less likely to be  disciplined  by licensure  boards  than 
were  physicians,  even  though,  as we noted  earlier,  dental  boards  may be  a more 
important  front  line  of protection  for consumers  than  are  medical  boards. 
It would  be  inappropriate  to suggest  that  there  is any proper  number  of disciplinary 
actions  for  a board  or to overemphasize  their  importance  as an indicator  of a boards 
capacity  or effectiveness.  Yet  it would  also be inappropriate  to ignore  this factor.  In 
this context,  it is well to note  that  in a report  on medical  boards,  the  American 
Association  of Retired  Persons  advised  that  the  simplest  way to determine  how well a 
board  is performing  is to determine  how many  disciplinary  actions  it is taking.ll 
11 CONCLUSION
The  stimulus  for this report  was our  prior  finding  that  State  dental  board  officials were 
often  reluctant  to license  out-of-State  dentists  because  of concerns  about  the  capacity 
and  readiness  of many  of their  counterpart  boards  to carry  out  their  disciplinary 
responsibilities.  The  information  presented  in this report  supports  their  concerns,  but 
its significance  goes beyond  the  licensure  of out-of-State  dentists  to the  more  basic 
issue  of providing  adequate  protection  to the  consumers  of dental  services  in all the 
States. 
Given  that  the  licensure  and  discipline  of dentists  is essentially  a State  responsibility,  it 
is the  State  boards  and  the  State  governments  of which  they  are  a part  that  must  take 
the  lead  if the  limitations  identified  in this report  are  to be  addressed.  Those 
limitations  affect  the  boards  capacity  to identify  dentists  warranting  investigation,  to 
conduct  thorough  investigations  that  will facilitate  responsible  decision  making  about 
how a board  should  proceed  with a case,  and,  when,  necessary  to take  disciplinary  and 
corrective  action  that  will protect  the  public  and be  fair to the  dentist  involved. 
The  Federal  government,  as indicated  at the  outset  of this report,  has  a considerable 
interest  in how the  States  address  the  limitations  of their  dental  boards.  In this 
context,  one  important  way in which the  Public  Health  Service  (PHS)  might  help  the 
State  boards,  but  still respect  the  primacy  of their  role,  is to extend  some  financial 
support  for the  development  of a self-assessment  instrument  for the  boards.  Such an 
instrument,  if developed  by representatives  of dental  boards,  could  serve  as an 
important  stimulus  for boards  to develop  consensus  on key indicators  of their 
performance,  to collect  data  in accord  those  indicators,  and  then  to compare  the 
results  over  time  and  even  across  States. 
The  PHS,  through  the  Agency  for Health  Care  Policy and  Research  (AHCPR),  has 
funded  The  Federation  of State  Medical  Boards  to develop  a self assessment 
instrument  for State  medical  boards,  with notable  success. *2 Similar  support  whether 
through  AHCPR  or the  Bureau  of Health  Professions,  oriented  to dental  boards,  the 
only other  State  licensing  boards  mandated  to report  their  disciplinary  actions  to the 
National  Practitioner  Data  Bank,  could  build  upon  the  prior  project  and  have  similar 
benefits. 
12
 APPENDIX  A 
NOTES 
1.  Suzanne  W. Letsch,  Helen  C. Lazenby,  Katherine  R. Levit,  and  Cathy 
A. Cowan,  National  Health  Expenditures,  1991, Health  Care Financing 
Review  14 (Winter  1992): 29. Federal  Medicare  expenditures  for dental 
services  are  only a few million  dollars  a year  as they  are  limited  to 
surgery  related  to the jaw  or facial  bone. 
2.  See  Letsch,  et al., p. 29. 
3.  U.S. Department  of Commerce,  Bureau  of the  Census,  Stat&ical 
Abstract  of the  United States,  1992, Table  160, p.  109.  Based  on data 
supplied  by the  American  Dental  Association,  Bureau  of Economic  and 
Behavioral  Research. 
4.  U.S. Department  of Health  and  Human  Services,  Public  Health  Service, 
Healthy  People: National  Health  l+omotion  and Disease Prevention 
Objectives,  DHHS  Publication  No. (PHS)  91-50212,  1991, p. 350. 
5.  Ibid.,  pp.  352-61.

6.  In particular,  see  State  Medical  Boards  and  Quality-of-Care  Cases:  Promising

Approaches,  OEI-01-92-00050,  February  1993; Performance  Indicators,

Annual  Reports,  and  State  Medical  Discipline:  A State-by-State  Review,  OEI-

01-89-00563,  July  1991; State  Licensure  and  Discipline  of Dentists,  0AI-Ol-88-

00580, August  1988; and  Medical  Licensure  and  Discipline:  An  Overview,

P-01-86-00064,  June  1986.

7.  See,  for examples,  American  Medical  Association,  Physician  Competence:  Whose
Responsibility:  Conference  Proceedings, April  7-9,  1988; U.S. Department  of

Health  and  Human  Services,  Public  Health  Service,  Agency  for Health  Care

Policy and  Research,  issues in Medical  Liability: A  Working Conference,  Mary  L.

Grady  and  Randie  A. Siegel,  eds.,  1991; and  U.S. Congress,  Office  of

Technology  Assessment,  The Quality of Medical  Care: Information  for
Consumers,  OTA-H-386  (Washington,  DC:  U.S. Government  Printing  Office,

June  1988).

8.  See  EH  ONeil, Health  Professions Education  for  the Future: Schools  in Service
to the Nation  (San Francisco: Pew Health  Professions  Commission,  1993),  51.  A

major  reason  for dentists  being  subject  to lesser  oversight  is that  about  69

percent  of them  conduct  solo practices.  See  American  Dental  Association,  me

A-1
 1991 Survey of Dental  Practice: General  Characteristics of Dentists,  April  1992, p. 
2. 
9.	 See  Federation  of State  Medical  Boards,  Elements  of a Modem  State Medical 
Board: A  Proposal,  1989, p. 3. 
10.	 In a recent  article,  Damiano  et al. also reported  significant  variations 
among  the  States  in disciplinary  actions  and  among  State  professional 
associations  in peer  review  actions.  Such variations,  they  concluded 
suggest the  need  for modifications  to improve  the  licensure  and 
disciplinary  process  to ensure  performance  in accord  with accepted 
professional  standards.  See Peter  C. Damiano,  Daniel  A. Shugass,  and 
James  R. Freed,  Assessing Quality  in Dentistry:  Dental  Boards,  peer 
Review  Vary  on Disciplinary  Actions,  Journal of the American  Dental 
Association  124 (May  1993):  130. 
11.	 See  American  Association  of Retired  Persons,  E&ective Physician  Overnight: 
Prescription for Medical  Licensing  Board Reform,  1987. 
12.	 A task  force  of the  Federation  of State  Medical  Boards  developed  a 
lengthy  self-assessment  instrument  which it sent  to all State  medical 
boards  for comment  and  then,  upon  revision,  for their  own use.  Many 
State  boards  have  completed  the  assessment  instrument  and  have  sent  in 
their  results  to the  Federation.  The  Federation,  upon  the  receipt  of 
such results,  enters  the  data  into  a common  data  base  incorporating  the 
information  submitted  by all boards.  It then  returns  information  back  to 
the  State  boards  in a manner  which  allows them  to compare  their  results 
with those  of other  States.  At the  annual  meeting  of the  Federation, 
held  in April  1993, many board  representatives  reported  that  the  self-
assessment  instrument  and  process  associated  with completing  it were 
helping  in identifying  ways of improving  their  boards  capacity. 
A-2