Corporate Dentistry – The New Oral Cancer

Dentistry was a fairly happy profession when I grew up in the 1960s and most of the 1970s. The invention of the high-speed air rotor turbine in the late 1950s had made practice so much easier and more efficient. Bonding resins were just being introduced that would revolutionize anterior fillings. The new Medicaid program paid dentists virtually their normal fees for treating a whole new population of patients. Life was good for dentists, and getting better for dental patients.

Back then the average practice was owned by a single dentist, employing one hygienist, and having three treatment rooms or at most four. There were a few offices where pairs of dentists worked. Sometimes specialists like oral surgeons would pair up to own two office locations, mostly to trade off emergency call on weekends.

What insurance plans existed were based upon realistic fees of the area. If they were not, most all dentists would shun them and the plans would fail.

Although dental school was the most expensive of all professional educations, it did not demand the king’s ransom that it does now. School loans were much more limited back then. Often students would earn money during studies to pay for their educations. Qualified students took scholarships would pay the whole cost of dental school, plus living expenses, in return for four years of military service. The average student had a minimum of debt at graduation- nothing like the quarter million + dollars that is so common today. Many students, including me, graduated debt-free.

When a student graduated from dental school, he had the following options:

1. Join the dental corps in the military and gain more experience while earning a modest salary.
2. Take salaried government jobs in prisons, the Public Health Service, of the Indian Health Service. These jobs were few in number and often in remote locations.
3. Take out a loan and buy the practice of a retiring or deceased dentist.
4. Apprentice as a hired associate with a more experienced dentist, and buy practice equity in time with the goal of become a full partner or outright owner.
5. Borrow money and start a new practice, like a few of us high-risk takers did!

Those were about all the options for young dentists! It was rare that a dentist failed and bankrupted. Seldom was it caused by lack of patients. Most of the time is was due to poor money management or problems with addiction.

If the young dentist took options 3 or 5 above and worked hard and kept out of trouble, he could earn an adequate income to support a family. After practice debt was paid off, his income would increase to provide the niceties of life.

Going into practice back then was a lot cheaper. The average office was a little over 1000 square feet. There were no computer networks in those decades, so the bulk of the cash outlay went for dental chairs, control units, and x-ray machines in the treatment rooms, and a steam sterilizer for the instruments. The only major expense for the front office was an electric typewriter, as phones were often rented from the telephone company!

Federal Planning Went Wrong Back Then, Also!

Just about the time the benefits of fluoridated water were kicking in and reducing decay, the Federal Boys were convinced there was soon going to be a drastic shortage of dentists. Starting the in mid 1970s, they began blackmailing dental schools to increase dental class sizes every year. They did this by withholding money called “capitation funds” from dental schools unless they increased class sizes by a proscribed amount.

These extra dentists where dumped on the market in the late 1970s just in time for the economic slowdown. I remember in my senior year of 1979 talking to dentists in different areas of Georgia, hoping to find a spot to practice or a job offer. Instead of being encouraging, every one I talked to pleaded with me not to locate close to his practice, claiming there was already a shortage of patients. The two dental schools in Georgia were together pouring out about 170 new dentists a year, and flooding the state with dentists. Thank you, Federal Government, for your inaccurate predictions and subsequent meddling! It created an oversupply of young dentists looking for jobs, and that meant the wages they could command was much lower.

A few enterprising dentists saw the opportunity of hiring labor really cheap and began opening branch offices, principally in shopping centers. A factor making this easier was recent court rulings striking down all restrictions on professional advertising. One owner of a chain of offices told me he spent $30,000 a month in Yellow Pages advertising.  This was in 1985!

I lasted all of six months in one of the Atlanta dental clinic chains that shall remain nameless. Patient care, although never top notch, was passable. There were not many liberties taken with billing. If a claim was sent to an insurance company for a filling, the filling most certainly had been done.

Caution against fraud and outright malpractice was exercised because the owners of the branch clinics were licensed dentists. They wanted to be at least marginally in compliance with state practice laws. The owner dentists would put their names on every office door, even if they only treated one patient there per month. If they were caught with hanky-panky in the offices, their own licenses could be suspended, or even permanently revoked. Yes, the owners encouraged overtreatment of patients to improve the bottom line, but they made sure the overtreatment was  passable in quality. None of them wanted state board investigators on their back.

About this time insurance companies noted the oversupply of dentists, which gave them increased their negotiating power. They demanded 20% fee reductions in some of their plans. An even worse abomination was the Dental Maintenance Organization  (DMO) contract, in which dentists took all the actuarial risk, and it was difficult to make any profit at all treating patients. However, despite their increasing numbers, few dentists would sign up for these jokes of benefit plans.

In 1991 Congress and the President passed a bill which seemed innocent enough, but in reality was one of the most intrusive and costly in US history. This was the Americans with Disability Act. Formerly,  it was common for dentists to have offices as small as 900-1000 square feet. Under the new ADA, with its requirements for huge bathrooms and wide halls, this was impossible. New office space for a single dentist could rarely be smaller than 1200 square feet.

In essence, this increased the cost of opening new offices for dental graduates   Not only that, but increased leased space meant increased monthly rents. A year or so before, the emergence of AIDs had increased practice costs quite a bit by virtue of much more extensive sterilization protocols. Starting and operating a new dental practice just got a great deal more expensive at a time when it was harder than ever to turn a profit.

 Corporate Suits Take Notice of Dentistry

Dental employment was in a bit of a slump when I graduated in 1980, thanks to the Feds meddling with class size of dental schools. However, my friends in medical school had bright prospects and were readily employed for the most part.

Medical advances like organ transplants were being made routine. That plus the high inflation of the time was starting to make politicians leery of the increases in cost of health care. In 1980, most medical practices were still owned by physicians, although groups were beginning to appear, such as those that staffed hospital emergency rooms.

Medical expenses continued to climb in the 1990s, causing the Feds to worry about Medicare and Medicaid costs. The thinking of the time was that large clinical operations like HMOs could drive down the cost of health care. I am not sure of the enabling legislation, but corporations like Kaiser Permanente were allowed to employ physicians. It became more and more common for corporations to own medical treatment facilities, and employ physicians on a salaried or commissioned basis.

Technology continued to march on and increase medical costs, and government and insurers continued to keep medical fees stagnant. The profit potential of corporate medical clinics was limited, while the the liability costs were enormous in potential.

The decade 2000 to 2010 can realistically described as one of the decline of the American middle class. The Federal Reserve loosened monetary policy in preparation for the Y2K crisis that was supposed to appear but never did. This was one of the causes of the tech-telecom boom and bust, which made a lot of personal net worth disappear. The Fed loosened monetary policy again after the 9/11 terrorist attacks, causing the real estate boom and subsequent bust. Even more middle class assets were lost in the housing bust than in the tech bust. Meanwhile, the Chinese we emerging as fierce competitors in manufacturing. Many US jobs were disappearing, and US standard of living was declining as a result.

There was tremendous price pressure on the health professions. Medical had taken it on the chin before; now it was dentistry’s turn.

Corporate America had been watching with interest the chain clinic concept developed by entrepreneurial dentists, using the cheap labor of recent graduates. Now they wanted a piece of the action in a profession they saw as having less liability risk than medicine. The problem was that most states had laws on the books permitting only licensed dentists to own dental practices.

The first corporate target was orthodontic practice, as orthodontists were the dentists most in oversupply. It also seemed that orthodontics would be the easiest dentistry to mass-market. One orthodontic management company even tried to sponsor a residency program obligating graduates to be corporate employees for a time! Orthodontic management companies were the rage in the stock market for a while, until they crashed, and some bankrupted.

Dental practice statutes to protect patients were designed with dentist-owners in mind. The worst penalty possible was permanent revocation of state licensure. Only dentists were at risk. But that was logical, because until that time dentists were the only ones who could own offices.

To skirt around state practice law, corporate owners posed as “dental management companies.” The fiction was that the dentist treating patients in the facility was the actual owner. The dentist, in turn, employed the corporate entity to handle the business functions of the practice. This relationship was codified in long, tedious contracts. Facilities could be added to the corporate roster by:

1. “Affiliating” the practice of an existing dentist with the corporation. Often a combination of money and corporate stock was given as compensation. How the dentist could still be the owner of the practice after accepting a bulk payment from a corporation for rights to “manage” his practice is beyond my comprehension, but that was the official line.
2. Constructing turnkey facilities, then recruiting dentists to be the clinicians and “owners.” Often these dentists were right out of school with little clinical experience.

The fiction of an employee being an owner should be obvious to anyone having a functional cerebral cortex. True ownership can be determined by:

1. Who has the power to sell the practice and pocket the gains?
2. Does the power to replace or eliminate the management company exist?
3. Whose signature is necessary for check-writing?

In no cases that I am aware do the dentist(s) have these powers in corporate clinics.

Having tidy contractual relationships in place, unchallenged by any state except the valiant North Carolina Board of Dentistry, corporate America was ready to run amuck in the dental world.

Dental practice laws were written for good reason with protection of the patients as the goal. States wanted dentists to suffer consequences if patient welfare was not given priority. If a dentist performed fraudulently or incompetently, his license would be taken away. Not only would his income disappear, but the equity in his practice would decline fairly quickly.

Since corporate officers held no dental licenses, no such punishment could be meted out to them The license of the sham-owner dentist could be revoked, but a new sham-owner dentist could be quickly obtained by corporate officers.

As most sham-owner dentists were paid on a complicated commission structure, dental management companies were free to sign up for any dental benefit plans, no matter how low-paying. When they contract with DMOs, almost never do treating dentists receive a commission on the capitation payments. With such plans, the dentists are just told they have to work harder, or do more patient procedures, in order to make a commission. Many young dentists face crushing student debt burdens, and losing employment would be financial disaster for them. Knowing this, they are loathe to refuse revenue dictates (“goals”)  by their corporate masters, whether patients need the treatment or not.

Although always denying it, corporate officers introduce severe distortions in the dentist-patient relationship. When something goes wrong, as a malpractice lawsuit or a patient death, the corporations usually get off free, as they can always point to the licensed dentist who performed the clinical treatment and is posed as the “owner.” It gets lost on juries that the dentists were coerced into unwise treatment by their “management company.”

One young dentist told me his corporate employer had videotape surveillance in all treatment rooms at all times! Talk about a violation of patient privacy! This dentist examined an elderly patient with a clotting disorder that needed an extraction, but refused to treat the patient until a medical consult could be arranged. The next day he was harangued by his non-dental employer for losing revenue by not doing the extraction! No doubt that this sort of pressure is behind many of the child deaths that occur when too much treatment is tried on small children at a single visit!

It is heartbreaking that intelligent young professionals are put in situations that force ethical compromise and substandard treatment. Yet fewer and fewer employment opportunities exist for young dentists outside the corporate world. Why is this?

1. The military services are downsizing their dental officer force, and using corporate contractors to treat troops instead of military dentists.
2. Hurt by low interest rates on their retirement assets, older dentists are practicing longer and not selling their practices. Even dentists who retired are coming back to practice because of need for more income.
3. Experienced dentists in their 50s do not have the excess patients that would provide sufficient income for a young dentist-associate. The older dentists don’t even have enough patients for their own sustenance, much less to spare for another dentist. Not a month passes that I don’t get a call from a recruiting agent trying to find a position for a newly graduated dentist.

Corporate money is a powerful tool with politicians. When North Carolina tried to pull the plug on corporate dental practice takeovers, the big guns were deployed to that state by affected corporate interests. Just as HMOs did in decades passed, dental corporations sing the siren song of cost containment and lower fees to the public. It plays better with politicians than lobbying for shareholder value.

The most unfortunate thing about the advent of corporate dentistry, after lowering the standard of care, is the lowering of public image of our profession. When inexperienced dentists are pressured into taking unwise risks and a fatality results, the public blames it on the dental profession.  Next thing you know, voters want more intrusive government supervision of dentists. Seldom is it realized that the problem is not incompetence in our profession, but perverse incentives inherent in the corporate dental business model.

What can be done? Well, ownership of a dental practice could be codified so the corporate clowns could not masquerade as “management companies.” Corporations could be forced to divest from clinics unless it could be shown that dentists are the actual owners, by virtue of several tests of ownership. Contracts that clearly violate state practice law could be voided by courts. Losing offices one at a time would be devastating to corporate dental chains.

Private equity investors tend to be herd animals. I am old enough to remember the rush to shopping mall dentistry, which was supposed to be the wave of the future. It failed miserably. Then there was the rush to the nirvana of Orthodontic Management Companies, which largely disappeared. It could be that after being slammed with penalties for billing fraud, bait and switch, and other consumer hanky-panky, corporate dental clinics will be seen as places for the public to avoid. Already I have encountered a Facebook page dedicated to complaints against one dental chain, and a whole website dedicated to exposing the hijinx of just one location of another national dental chain!

Word spreads around quickly in the information age. I am hoping the truth will eventually get out about the corporate dental model. This essay, if widely read, may be one more nail in the corporate dentistry’s coffin!

Kim Henry, D.M.D.

January 11, 2014

Do Gadgets Make Good Dentists?

A prospective patient came by one day to interview me. She was looking for a new dentist for her family. She and her husband were intelligent people and owned two successful businesses. This woman was doing her best to select a good dentist for her family- or so she thought.

The questions she asked centered on what expensive gadgets I had bought for my office. Did I have digital x-rays? Did I have a laser? How about one of those expensive CAD-CAM machines that makes crowns while patients wait?

Sorry to say, I am a conservative business owner who is leery of incurring debt to buy expensive and unproven equipment.  I must have disappointed this woman, as she did not return. Doubtless she found a dentist with most of the expensive gadgets she thought were standard for good dental treatment.

It is unfortunate, but a lot of people think many expensive gadgets = quality dental care. This is in no small part due to manufacturers’ propaganda. In the high-overhead professions of both medicine and dentistry, it is a hard sell to get docs to buy expensive new equipment. Nobody wants to be an early adopter who spends $50,000 on an invention that doesn’t live up to its expectation.

So the trend is to first advertise any new expensive technology directly to patient populations. Without a professional background and access to scientific journals, it is easy for the average patient to be convinced that some new gadget is the greatest thing since sliced bread.

The next step is for manufacturers to post an online list of dentists who bought their product, so patients can view and patronize these practitioners. In this way, manufacturers seek to reward dentists who make a large purchase of their new equipment.

Am I against new technology? Absolutely not. My problem is that much of it does not work out to be practical or economical. Someone has to pay for this expensive stuff. Invariably it is the patients via higher fees. It is instructive to look through the “For Sale- Used” ads in my dental journals and see what is available. Invariably I encounter expensive items that were highly touted three to four years prior, but did not end up being a worthwhile investment. These gadgets sell used for pennies on the dollar.

Would digital x-rays save my patients radiation over my top-notch film and equipment? Not much, if any. Intraoral digital x-ray sensors are uncomfortable in the mouth and cannot be sterilized. The chief convenience is immediate reading by the dentist.

How about spending thousands of dollars for software to trace and measure parameters of skull x-rays for orthodontics? It would save me time, but considering the fact I analyze about eight such x-rays a year, would it make sense? Hand tracing and measurement take me a little time, but the result is just as good.

Would investing over $100,000 in a CAD-CAM machine to make crowns in the office do better than my lab technicians? Not from the examples I have seen. And the crowns still have to be custom-stained to look authentic. But again, it is convenient for the dentist not to have to schedule a second patient appointment for cementation.

Would a $40,000 laser work magic on my patient’s gums? Well, it is not true that patients don’t need anesthetic injections before using lasers. These machines cut very slowly, and stink when they do. The only convincing use I have seen for lasers is to cut gums around implants, where my electrosugery unit cannot be used.  In dentistry at least, lasers seem like expensive toys.

By now I am sure you get the picture. With high enough patient volume, there are a few technologies that sometime make sense for a practice. These are few and far between. For every technology that proves itself in medical or dental practice, there might be nine that disappear because they do not live up to expectations.

In dental and medical practice, if you don’t get diagnosis and treatment planning right, no technological marvel in the world will make up for it. Technology is no substitute for experience in surgery. The main effect of technology is to increase doctor productivity. In general, the number of high-tech gadgets in an office is not a good indicator of quality of treatment you will receive.

New help for Snoring

Many of us have significant others in our life that snore. Many these people also have mild sleep apnea. At the minimum, they make life difficult for others in the household. At the worst, they may be adding an additional risk for heart disease.

Many people cannot tolerate the CPAP machine. It may be overkill for mild sleep apnea anyway. For these people, a simple oral device that advances the lower jaw to clear the airway might be just the thing.

It takes a sturdy appliance to hold a patient’s jaw forward all night long. In our experience, the Thornton Adjustable Positioner (TAP) appliance is the best of the bunch. Not only is it sturdy, but its adjustment features allow each patient to find the perfect advancement position for comfort and effectiveness.

I used this device to reduce my own snoring for several years before orthodontics. Once my braces were off, I procrastinated about having a new one constructed, until my wife complained enough.  Finally I had the current improved version of the TAP constructed, which is much more comfortable. My wife reports my snoring is down significantly.

These things are not cheap. All totaled, they cost $1200. If you have had a sleep study, there is a chance that you may get your medical insurance to cover a portion of the cost.

Not everyone is a candidate for an intraoral sleep appliance. Almost all natural teeth must be present to anchor a device like the TAP. It is not possible to wear when undergoing orthodontics.  For those who can wear them, however, oral appliances may offer relief to the snorer and loved ones who try to sleep in the same house!

When should my child have braces?

 I am often asked this simple question by parents. And I have a simple, but not very satisfying, answer- it depends!

There are a few problems that I would correct even in a 5- or 6- year old.  These are “crossbites”, where either the upper front or back teeth are locked inside the lower teeth.  If left uncorrected, cross bites will soon make the child’s jaw grow abnormally crooked or long. Often such abnormal growth may be remedied only by extensive surgery later in adulthood!

This child of 8 has her upper incisors locked behind her lower incisors in crossbite. If untreated, this will become a very complicated surgical-orthodontic case.

Another important interceptive strategy in children this young is to stop thumb or lip sucking habits, or modify the way the tongue moves during swallowing.  Teeth can be moved into very unnatural positions by unusual tongue, lip, or finger habits.  If not corrected early before orthodontics, tooth movement will not be stable.

Many things we do at an early age can minimize or even prevent your child’s need for braces. The most important is keeping baby teeth in the mouth until they are ready to come out. Pulling back baby teeth early has severe consequences. It is guaranteed to cause the need for complicated orthodontics later!

The earliest age we usually treat children orthodontically is age 7 to 9.  This is called “Phase I treatment.”  We can make most of the corrections in difficult cases here, leaving only a little to do when all the permanent teeth come in at age 12 to 13. There are many advantages to Phase I treatment. The most important are that children this age cooperate better, orthodontic corrections are easier and more stable, and we can more often avoid extractions of permanent teeth. The most common Phase I treatment we do is expansion of the growing arches, to make sufficient room for eruption of the permanent teeth.

This child had a narrow palate, making it impossible to erupt the permanent canine teeth. A “Hyrax” ex-pander was placed in the roof of her mouth. Over the course of several days the device was expanded, until there was enough room to bring the impacted teeth into the arch.

Usually too many teeth are erupting at age 10 and 11 to do fixed braces. All we can do is place space maintainers to preserve every bit of space as the last baby teeth are lost. This age may still be a critical time for treatment, as far as growth alteration is concerned. Some girls are nearly finished with bone growth at the end of their 11^th year.

Age 12 and above, when all permanent teeth are in the mouth, has been the traditional time of most orthodontics. Most Phase I cases need final correction at this age. However, even this is variable.  I do not know why, but many children are getting all the permanent teeth in the mouth earlier.  I am now able to put complete braces on some 11 year- olds and finish the treatment by age 12.

A critical event occurs at age 18. Two bones in the roof of the mouth fuse together, and no longer can be expanded easily. It is at this point that orthodontics can really be slow going!

One of the many advantages to your child’s treatment in this practice is my many years of experience doing orthodontics, beginning in 1987. At each dental checkup, we monitor your child’s growth and tooth eruption. In fact, I spend more time doing this than checking for cavities! We will alert you to critical times for possible orthodontic intervention, so your financial outlays and time in braces can be minimized.

Kim Henry, D.M.D.

 

 

The Great Silver Filling flim-flam ~ or~ Straight talk about a good Filling Material

“Aren’t those silver fillings you put in people’s mouths poisonous?” Patients ask me questions like this weekly.  They think they might be victims of an unsafe filling material, but they are instead victims of self-serving fear mongers. There is so much misinformation about health issues in the news media, it is no wonder many patients are confused.  It seems like the purpose of reporters is to scare us to death with sensationalism, rather than to inform us.

Silver amalgam fillings were placed by the Chinese as early as 1400AD, and in Western countries since the early 1800s.  This material has saved countless of millions of teeth from extraction.  Silver amalgam is economical, easy to place, and durable.  Current formulations are about 59% of a mixture of silver, copper, and tin, and 42% mercury.

“Mercury!  Isn’t mercury a poison?”  This is always patients’ next question.

Yes, if you ingest elemental mercury or sufficient amounts of methyl mercury, it is.  Many common everyday items contain amounts of dangerous elements, bound together in stable molecules.  Elemental chlorine gas is lethal if inhaled.  Bound together with sodium, it is the table salt you ingest in food every day.

It is true, silver amalgam contains mercury, but it is bound together in a stable alloy that poses no health risk.  Silver fillings have been the subject of countless scientific investigations. Although it is true that trace amounts of mercury are released in heavy chewing, the amounts are inconsequential and have not been found to pose a health hazard.  Eating fish, especially tuna, releases more mercury in your body than do silver fillings.

The most elemental mercury is released from silver fillings during their placement and during their removal from teeth.  Now think about this: my assistant and I remove old silver fillings and place new ones in teeth during much of our workday.  If silver fillings are so dangerous, don’t you think dentists and their assistants would be the people who were very ill?

Now why on earth would people try to scare you into thinking fillings in your mouth are poisoning you?  There are two reasons- publicity and money.  Please examine people’s motives before you believe what they say.

If one researcher concluded that drinking tap water was a dangerous health risk, it might make headlines on the news. If ten researchers concluded that drinking tap water was safe, do you think you would hear about it?  No- It wouldn’t be news, because it would not be contrary to what anyone believes.  It wouldn’t scare anyone, nor generate any publicity!  For a researcher, claiming silver fillings cause a variety of serious illnesses is a sure way to be an instant celebrity. It also gains publicity for his university employer, which increases the researcher’s chance of promotion.

Likewise, if a dentist tells you that your silver fillings are safe and should stay in your mouth, he will earn no money from you.  However, if a dentist acts unethically and claims your silver fillings are toxic hazards and should be replaced, he stands to make money from replacing them with more expensive types of fillings.  Think about it!  Where is the motivation?

Two beautiful new and polished silver amalgam fillings, alongside an older amalgam on the left.  Amalgams like these may easily last 20 years, and often 40 years in the mouth.

Now that we have gone over all the reasons why amalgams are safe, why should you consider using them in your mouth, instead of types of fillings?

1. Amalgams are cost-effective.  They have the lowest cost per year of useful life of any filling material.
2. They are easy for the dentist to place, even when there is moisture.
3. It is relatively easy to get a good contact between a silver filling and an adjacent tooth. Inadequate contacts can cause food impaction and gum disease.
4. Post-op sensitivity is usually minimal and short-lived.
5. Silver fillings actually seal better with increased time.
6. They are more decay-resistant than resin-based or resin-cemented fillings.
7. Silver fillings can be repaired or added to.
8. The amalgam material is not so hard that it wears the opposing natural teeth.

Silver amalgam fillings remain the most durable filling material for back teeth after gold.  Gold fillings are wonderful, but are more complicated to do, and cost several times as much as silver amalgams. Science has made great improvements in white resin fillings, but such fillings still do not last nearly so long in back teeth.  It is not rare for silver fillings to last 30 years, and it is possible for them to last 60.  There is no reason why you should have silver fillings replaced for health reasons.

Dr. Kim Henry

May 3, 2002

 

 

 

 

Why remove my wisdom teeth? They’re not bothering me!

It’s a fair objection.  If a body part is not symptomatic, why remove it?  After all, I would have objected if a surgeon had wanted to take remove my appendix prophylactically, before I developed appendicitis.  Why should wisdom teeth be any different?  Why should third molars (wisdom teeth) be removed before symptoms occur?

It is because in most cases, the damage from wisdom teeth occurs gradually, with no symptoms until very late.  But it nearly always occurs- either damage from gum disease, bone cysts or from cavities on the back of 2^nd molars.

The gums around the wisdom teeth are usually not the type most resistant to gum disease.  Added to this is the fact that the wisdom teeth usually erupt in the corner of the jaw, allowing gums to partially cover them.  These two factors predisposes patients to have gum disease around wisdom teeth.

Now we would not worry if wisdom teeth lost bone and ligament support around them until they got loose and fell out.  The problem is that if wisdom teeth are left in, periodontal destruction almost always occurs between the wisdom teeth and 2^nd molars in front of them.  When the wisdom teeth are finally lost, the second molars are often weakened due to ligament and bone loss.  Often, when patients maintain their wisdom teeth over many years, they end up losing both the wisdom teeth AND the 2^nd molars due to gum disease.

Wisdom teeth often jeopardize 2^nd molars in another way.  Often food gets trapped between wisdom teeth and 2^nd molars and cause decay. My patient histories are replete with many cases like this:

 

This patient developed decay on the back of his 2^nd molar (black spot on the right of the middle  tooth) because of his wisdom tooth (on the right.) By the time he realized it, the decay had infected the nerve. This meant a root canal, buildup filling, and crown were necessary on the  2^nd molar in order to save it.

Most patients have trouble cleaning between the rest of their teeth with floss.  How much more difficult it is to clean around wisdom teeth! Honestly, I have met few patients who can do it well.

Should unerupted wisdom teeth also be removed?

A third, rarer reason to remove wisdom teeth is to prevent cysts and tumors in the bone.  Around each unerupted wisdom tooth is a sac of cells which formed the tooth, call the dental follicle.  Especially in the lower jaw, these cells sometimes expand, forming a tumor which can destroy a big part of the lower jaw.

The presence of an impacted wisdom tooth may also weaken the jaw structurally.  Sometimes I have seen accident victims in which the jaw broke at the location of an impacted wisdom tooth.  Had the space been filled with sturdy bone, the jaw fracture might not have happened.

Just because a wisdom tooth is unerupted, does not mean it will stay that way. Wisdom teeth can sometimes erupt and cause inconvenient problems later in life- even if a patient has complete dentures!

Are there any situations where you might leave wisdom teeth in the mouth?

Yes, there are a few.

When patients have four premolars removed for orthodontics, all molars are positioned farther forward in the mouth. Occasionally, there is enough room for the third molars to erupt and be maintained in good health.

Another instance is when 1^st or 2^nd molars are lost.  Occasionally, the wisdom teeth may be moved by orthodontics to be good substitutes for the lost teeth.  But it is a very difficult movement, except in young patients.

When patients lose their first and second molars, wisdom teeth can be used to anchor a removable partial denture, especially on the lower arch. Wisdom teeth are often not shaped very well for this use, but it can be better than resting the partial denture on gums alone.

In elderly individuals, especially those on drugs to prevent osteoporosis, I might leave wisdom teeth alone, whether unerupted or not.  Sometimes the surgical risk outweighs the benefits of extraction in older patients.

If they are so useless, why do humans still have 3^rd molars?

The trend has been toward shorter jaws in mankind.  The higher apes have plenty of room for 3^rd molars, and some even have 4^th molars as well.  Through the years, man’s jaws have become shorter, but the size of his teeth has stayed the same.  The result is not enough room for the wisdom teeth, which are the last to erupt in the mouth.

 Kim Henry, D.M.D.

 July 25, 2007

What Causes Cavities?

When I ask patients with cavity problems to guess the origin of their problem, I occasionally get answers like these:

“It was some medicine I took as a child.”

 “My teeth were fine until I had my children.  They sucked all the calcium out of my teeth when I was pregnant. Then my teeth got weak and decayed.”

 “My parents had dentures.  I guess I inherited bad teeth.”

 “It must be from not brushing my teeth right.”

 Let us look together and see how decay really gets started, then go on to investigate how we may prevent it!

What is decay?

Teeth are made of minerals, and are the hardest organs of the body- much harder than bone!  Decay is a process whereby the hard enamel outside of a tooth is dissolved by acid.  Once decay gets through the enamel, the same acid dissolution progresses very quickly in the inner dentin of the tooth. If the patient does not get the cavity filled, decay invade the tooth root (containing nerves) and a toothache results.

So where does this acid come from?

It can come from a couple of sources.  The most common is from bacteria living inside our mouths.  Many of these sugars utilize for energy, and produce lactic acid as a by-product. It is primarily this acid which acts to dissolve teeth.  Bacteria can turn dietary sugars into lactic acid in only 20 minutes. Unless the mouth is rinsed or cleaned, this acid hangs around to dissolve teeth for a whole hour!  So you can see that a child who ingests candy most of the day will have an acid mouth all day, an inevitably have move than a few cavities!  An adult who sips sweetened coffee most of the workday will likely suffer from the same fate.

But adults frequently get acid more directly- by drinking soda pop!  Few people realize what strong acids carbonated beverages really are!  Carbonated drinks are such potent acids that they can dissolve teeth directly whether the soda is “diet” or has sugar in it.  I would estimate that 75% of adult decay I see is the direct result of excessive soda drinking.  And as if that were not enough, too many sodas can contribute to stomach ulcers and even osteoporosis.

Excessive daily soda pop intake caused characteristic tooth decay around gums.

Other sources of acid we sometimes encounter:

Chronic vomiting, as seen in bulimia and some other disorders, can erode teeth and also cause cavities.

We have noted lately many cases of gastric reflux, where small quantities of stomach acid enter the mouth.  This causes rampant destruction in your mouth, and should be controlled by prescriptions or surgery!

Don’t some medical conditions expedite decay?

Yes. Although not directly a cause of decay, any condition which dries the mouth can make your teeth more susceptible to it. Examples are doses of radiation to the head, using certain antidepressants, and antihistamines. We find that people that are mouth breathers are prone to more decay than those who can breathe normally through their nose.

Fluoride- our two-edged sword in fighting decay:

Even should physicians be unable to treat the above medical conditions, we still are able to stop decay- provided we have patient cooperation and fluoride.

Fluoride actually works two ways.  It has a toxic effect on decay causing bacteria. It also hardens tooth enamel and makes it more resistant to acid attack.  Interestingly, fluoride strengthens bone in the same way it strengthens teeth.  Physicians sometimes use fluoride supplement to treat osteoporosis.

For adults with decay problems, we often prescribe a fluoride gel to brush on the teeth at night just before bed, and a fluoride mouth rinse in the morning.  For really tough cases, including patients who have uncontrolled gastric reflux, we make custom trays to wear with fluoride at night.  With this heavy-duty preventive treatment, few patients get cavities!

Kim Henry, D.M.D.

 

 

“But I thought my cleanings were covered at 100%!”

That¹s what patients call to tell us when they get a bill for the balance on their periodic examination and cleaning appointments. Some are quite mad, and accuse us of ripping them off. They remind us that the insurance card in their hands plainly states “100% coverage for preventive treatment.”

What is going on? To understand, one has to grasp how the shell game of dental “insurance” has evolved over the years.

In the first generation of dental benefit plans, reimbursements were based on something called “UCR” fees. UCR stands for usual, customary, and reasonable. Fees were based on a percentile of real fee surveys within zip codes. They had a real resemblance to fees charged by dentists in the community. Sure, some insurance companies gamed the system by not updating their UCR fees with any regularity. But by and large, when insurers promised patients “100 coverage for preventive treatment,” the claim was generally correct.

In the second generation of dental benefit plans, called PPOs, fees were still based on some sort of UCR ideal. These plans were concocted to save employers money. They promised to deliver patients to dentists who participated (by signing slanted contracts) with plenty of patients, provided the dentists billed 20 to 30% less for procedures. Often this was the dentists¹ whole profit margin, so most resorted to procedure upcoding and other antics to make up the difference. The dental insurance companies really did not care. The important point of these plans was that they penalized patients for choosing their own dentists. A cleaning covered at 100% at a “participating” dentist would be covered at only 70-80% by a freedom-of-choice dentist.

In the latest generation of dental benefit plans, employers have flexed their muscle with dental insurers. Many now only pay companies a per-claim fee for administration, typically $5 or less. Employers now designate any “allowable” fee they wish, based solely on a cost target for their company. In these plans, any fee whatsoever can be designated for any procedure. For example, an employer can set $25 as an “allowable” fee for a dental cleaning, even though no dentists in the US may charge so little. The fee is merely a fairy-tale price concocted on the whim of the employer.

Meanwhile, the card given the employee still says “100% coverage.” But sadly, when employees use the benefits, they may discover the plan only covers $25 of a $90 cleaning. Few employees truly understand what is happening, and their anger is deflected onto the dentist. Instead, they should blame the employer, who is playing a deceptive shell game with its workers.

The whole driver of these shenanigans is the desire by employers to save benefit dollars. We can certainly empathize with that goal in this difficult economy for business. However, we think honesty with employees is a better path than deception. The honest thing to do would be to cut the benefit maximum, or lower percentage reimbursement for dental services. Unfortunately, that makes it a lot more obvious to employee-patients that benefits are being cut. Thus, the deception of employer-proscribed low “allowable” fees goes on.

We remind our patients once again that dental “insurance” is an inefficient contrivance born in an era of high marginal tax rates. The crucial test of your dental plan is whether it pays out more in benefits each year than the premiums you pay for it. With employers cutting benefit plan subsidies and at the same time lowering “allowed fees,” fewer and fewer dental plans are worthwhile. It seems remarkable, but if an employee is covered by a FLEX benefit or 125S Cafeteria plan, it is usually more economical to drop the dental benefit plan. Paying for dental expenses by a FLEX or Cafeteria plan is more efficient, and gives you complete freedom of choice in choosing dentists!

by Kim Henry, D.M.D.

Selecting a Dentist

How to select a dentist?  That is a good question. What is really important?

Is the dentist honest?  In the old days, patient selected professionals from affiliations in churches and civic organizations.  You picked a guy that acted honestly in his public dealings.  A guy that would cheat on his wife would probably try to cheat you in billings.  Sadly, people think choosing professionals this way is passé.

Is the dentist competent? What good are low fees if treatment is done incompetently?  Competency should be your next criteria. Dental lab technicians can tell you in a heartbeat which dentists turn in the best work.  But it may be difficult to get a technician to talk to you about this subject.  Any general dentist who is a member of the RV Tucker Gold Study Club (very active in Oregon), the Academy of Operative Dentistry, or the Academy of General Dentistry are probably very competent dentists.

Public records of your State Dental Board are an invaluable resource in screening dentists.  See if you Board has any disciplinary actions against dentists in your area for either dishonest or incompetent practice..  Look for actual consent orders against dentists. Not just complaints, as any disgruntled patient with a balance can lodge a baseless complaint.

Is the dentist reasonable in fees?  Naturally, you will find the highest fees in upscale parts of town.  Be aware that if you seek dentists with expensive gadgets like lasers or CAD/CAM machines, you will pay higher fees!  But the biggest way you will save money is by seeking a general dentist who does most work in-house. Former military dentists are likely to do more specialty procedures.  Ask a prospective office if the dentist does most root canals, difficult wisdom teeth, and implants himself.  Fees by general dentists are usually less than fees of specialists.

Is the dentist more interested in his profession or the money his profession brings?  A good indication is membership in state and local dental societies, as well as the organizations listed previously.  Beware of the professional fascinated with the expensive things in life outside the office. It’s pretty easy to pick up on this in conversation.  Ask a technical question about procedures, and a dentist interested in his profession will talk your ears off. You want a dentist who is truly fascinated by his profession, not one who merely views it as a means of income.

How not to select a dentist!

Preferred Provider listings- A great way to select against dentists with high ethics.

Yellow pages ads- Anyone can say anything in a phone book ad.  Courts have blocked professional associations from policing deceptive or misleading print advertising.

Referral from manufacturer’s websites- Manufacturers of expensive gadgets like lasers advertise to the public, and infer that any dentist with one of their expensive products is “state of the art.”  They give free patient referrals on their websites to dentists who purchase their products. Expensive gadgets are nice toys, but ultimately have little effect on the quality of treatment.

Anyone who advertises themselves as a “Cosmetic Dentist.”- There is no such recognized specialty in the profession.

Anyone who advertises themselves as a “holistic” dentist with a “metal-free” practice- You will have a scam artist for certain.

How To Save Money On Dental Treatment

The American consumer is feeling the squeeze in this recession. Families are faced with less income and higher fuel and food prices, and that means fewer discretionary dollars.  Family expenses must be scrutinized, and health care costs are included.

I have visited dentists and attended dental conventions all over the world.  There is no doubt that dentistry in the US is the best in the world.  But nobody claims it’s the cheapest! How can the consumer save money on dental care, without risking sub-standard care?  Here are some things you might try!

Utilize teaching institutions for treatment

If you are within a reasonable distance of a dental school, seek treatment there.  Treatment by pre-doctoral students averages about 33% of the fees charged by private dentists.  Be aware, however, that appointments will be very numerous and very lengthy.

If you live within commuting distance to a college with a dental hygiene program, you may get cleanings and x-rays done at an extremely low price. If you do this, it is always wise to see a regular dentist once a year.  While hygiene schools give great cleanings, they sometimes miss decay.  Thus, it is prudent to alternate visits between a private dentist and a dental hygiene school.  Most hygiene schools forward copies of x-rays to the dentist of your choice.

Choose dentists by reputation, not by advertisement

Anyone can say nearly anything in a yellow pages, radio, or television advertisement.  You will find guys that utilize these techniques have high patient turnover rates- for good reason!  As with any other professional, choose an individual that has demonstrated honesty and high personal ethics in your community.

Should you start with dentists on some “preferred” insurance list?  Probably not, as they often make up the difference in fees by charging for things that are usually included free with a visit.  Merely signing up to be a PPO provider involves ethical compromise, as one must agree to charge different groups of patients different fees for the same procedures.

Go easy on the cosmetic dentistry

Have back teeth filled with silver amalgam, instead of resin or porcelain.  Not only is silver amalgam safe and less expensive to start with, it lasts far longer than white plastic for back teeth.  Silver amalgam has the lowest cost-per-year-of-life than any other filling material.  If your dentist has quit using silver amalgam, you need to change dentists!

Smile makeovers can be done more economically with orthodontics than with veneers and crowns.  Traditional stainless steel brackets are cheaper and more trouble-free than white brackets.  Clear aligner orthodontics is very much more expensive!

Remember that the more aggressive cosmetic treatments that require cutting down teeth also have higher maintenance costs throughout life.

When contemplating tooth bleaching, remember that there is no difference in final result between bleaching teeth by wearing a tray at night, and having it done at the dental office.  In-office bleaching is at least twice as expensive, and often creates more sensitivity!  By waiting for whiter teeth a few weeks, you may save quite a bit of money.

Whatever you do, avoid practicioners who advertise themselves as “cosmetic dentists.”  There is no such recognized specialty, despite public perception. Every general dentist does cosmetic dentistry.  You can be certain that self-proclaimed “cosmetic dentists” will recommend significantly more expensive treatment plans!

Take the insurance burden off the dentist, and save!

Consumers can’t imagine the hassle dental offices deal with in getting insurance claims filed and paid.  Often a patient can negociate a better fee by offering to pay the dentist up front, then personally filing the claim and being reimbursed.  A good idea is to send claims registered mail, to make sure the insurance company can’t say they “lost” the insurance claim!  Expect discounts from dentists of 5-10% when you are willing to do this.

Dental insurance is an inefficient way of paying for dental treatment, as administration typically eats 30-35% of every premium dollar.  Far better to finance dental care through Health Savings, Cafeteria, of Flex-spending accounts.

Offer to barter for services– If you have any sort of useful skill, perhaps you can barter with the dentist dollar-for dollar. I have traded dentistry for cabinet work, yard work, piano tuning, painting, and roofing, to name a few.  Everybody wins in barter!

Don’t use cards to pay.

Dentists pay 2% and more for processing credit card transactions.  You are not as likely to receive a prepayment discount if you use a credit card.

Choose less complicated procedures, rather than shopping for the lowest price on a procedure.

Patients often call my office, shopping for the best price on a particular procedure, like a porcelain crown.  I understand what they are trying to do, and emphasize with them.  However, it is better to seek cheaper procedures.  Seeking the cheapest price on a procedure usually means finding someone who takes shortcuts on procedures.

For instance, rather than a porcelain crown on a back tooth, the patient might be satisfied with a crown made out of a non-precious metal like chromium-cobalt, which is more durable anyway.  Or to save even more, a large silver filling buildup could be done.

Find a general dentist who does most specialty work

Treatment by specialists is nearly always more expensive, and entails additional drive time.  Find a dentist who does most specialty work- root canals, implants, orthodontics, and wisdom tooth extractions in-house.  While relatively rarer, such dentists do exist, and usually offer fees 10-30% lower than specialists.  They tend to be middle age and older, and are more typically male.

 

Kim Henry, D.M.D.

October 13, 2008