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.

dental tooth decay 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



Tips on obtaining Good Orthodontics

You probably already know that we prefer orthodontics to crowns and veneers when improving patient smiles. Not only is orthodontics more a more cost-effective esthetic solution, but it requires less maintenance over time.

Patients are forever seeking orthodontic treatment methods that are fast, cannot be seen, don’t hurt, and don’t cost much.  Unfortunately, the “straight tooth pill” has yet to be invented!  However, if you compare orthodontics now to 40 years ago, great advances have been made.  We can put bonded brackets instead of bands on nearly every tooth, and nickel-titanium wires act much longer and more gently than stainless steel wires.  The result is faster and more comfortable orthodontics, with fewer extractions necessary.  Braces are so much easier for both dentist and patient than when I was a teenager!

There are a lot of good dentists out there doing orthodontics. However, I still encounter a lot of patients who have been in braces too long and paid too much. They fall prey to slick advertising, and don’t know enough to ask the right questions before commencing orthodontic treatment.  Knowing that an informed patient is better able to make good treatment decisions, I decided to write this article.

Who can do orthodontics?

Orthodontists attend a two-year residency after dental school, and by law must limit their practice to orthodontics.  There are plenty of them around, as you see in yellow-page ads.

Often pediatric dentists and general dentists who have taken additional coursework can treat the majority of orthodontic cases, reserving the most difficult for orthodontists.  A great deal of orthodontics in the US is done by dentists who are not orthodontists.  I am one of them, treating cases since 1987.  In many instances, general dentists may do orthodontics just to have more variety in their workday, and be willing to charge less for treatment than the average orthodontist.

Is it a good idea to use an orthodontic chain clinic you saw advertised on television?

These places employ orthodontists and sometimes general dentists on a commission basis.  Orthodontist-employees consider these clinics as merely a job to work until they can start their own practices.  Their goal is not so much long-term patient satisfaction as maximizing short-term compensation while they are employed.  Despite the slick advertisements, treatment in orthodontic chain clinics is almost never a good deal.

As with other consumer services, you will find the best service comes from small owner-operated businesses.

The problem with no-money-down and low monthly payment plans 

Never lose sight of your goal of wanting excellent orthodontic treatment finished in a reasonable amount of time and at a reasonable cost.  This may seem obvious, but many advertisements focus on providing braces with no money down and low monthly fees, never mentioning the total case price the patient is paying!  Heeding this advertising can be a BIG mistake!

Why?  Well, putting braces on is a big expense for the dentist, both in time and money.  It is a big risk if the patient decides not to continue treatment.  So many orthodontists advertising no money down plans put the brackets on gradually, over weeks or months.  This makes treatment last longer than it should.

Likewise, orthodontists who advertise low monthly payments do this by holding the patients in braces for far longer than necessary, just to make lower monthly payments for the patient.

Orthodontics should always be completed as quickly as possible!  Leaving brackets on teeth for longer than necessary can cause cavities and gum disease.  There are very few cases I have not finished in 2 years.  Most cases I have finish in 1 ½ years or less. Yet I encounter many children whose orthodontic treatment has spanned 3 years and more.  And when the patient or parent adds up the total they have paid, it is often the most expensive treatment around!

In review, be sure to ask the total case price and number of months in treatment.  It may be better for you to save money to pay more at the outset, to bring down monthly payments.

Are there any charges not included?

Now that you know to ask the price of the treatment and how long it will last, you need to ask something else.  Almost all dentists charge separately for the workup records, usually including panoramic and cephalometric x-rays, impression for models, and pre-op photos.  How much will these cost?

Some orthodontists charge separately for retainers.  It is important to add such charges when considering total treatment costs.

You will be moving to a new city in the next year.  Should you start orthodontics now and transfer to another orthodontist near your new home, or wait until you have moved to start treatment?

This is easy to answer.  ALWAYS try to avoid changing orthodontists.  The new orthodontist must take new mid-treatment records for legal protection.  YOU will pay for these. It is unlikely that the new orthodontist will use the same brand of brackets as you started with, making it hard to replace broken brackets.  No practitioner wants transfer cases!  Changing orthodontists mid-treatment will cost you lots of extra time and money.  It is better to wait to start treatment, except during growth-critical treatment of a child.

Should you undertake a “Phase I” early intervention for your child?

It is bound to happen.  Your child’s teeth might be really crowded at only 6 to 9 years of age.  You feel bad because your child may be teased at school, or may be anxious about the ugly smile.  So you take your child for an orthodontic consult.  A “Phase I” early orthodontic therapy is recommended, lasting 1 to 1 ½ years.  You are told that a second phase of orthodontics will probably be necessary at age 12 or later.

The way it is priced, this early treatment may eat up most of not all of any orthodontic insurance benefits.  Should you do it?

Probably not. Studies show little benefit in early intervention, except in very specific problems types.  What are these types of problems?

  •  Crossbite of either front of back teeth.  Untreated, this may lead to asymmetric jaw growth.
  • Severe shift of the midlines of upper and lower growth.
  • Developing open bite.
  • Deficiency of growth of the upper jaw.

If Phase I treatments seldom offer any tangible benefit, and increase the cost of treatment, why are they so often done?

  •  Pressure from parents to make their child feel better.
  • Frankly, some orthodontists fear that if they do not initiate Phase I treatment on the child, the parents will seek another orthodontist who will.  Not wanting to lose a patient, orthodontist initiate therapy, even if there is little long-term benefit.

We have seen Phase I treatments started too late, at age 9, and more permanent teeth start to erupt during treatment. The child is then stuck in braces for 3 or 4 years during Phase I AND Phase II combined.  The child’s cooperation wanes, cavities develop around the brackets, and the gums become very inflamed.

Unless you hear some very good reasons otherwise, Phase I treatments are usually not useful nor cost effective.  Many children erupt all permanent teeth by age 11 these days.  Save yourself the trouble and expense, and do the corrections in one concise treatment.

What about extracting teeth for orthodontic treatment?

It seems the pendulum swings from one extreme to the other.  Once upon a time, an orthodontic philosophy was popular in which premolar teeth were extracted in the majority of cases.  Now, some dentists are so zealous, they proclaim teeth should never be extracted for orthodontic treatment.

Fewer extractions are being done for orthodontics than ever before in my career.  However, there are still cases in which the teeth are just two big for the size of the jaw.  There is a limited amount of space that can be gained by expanding the arch, and driving molars backward is a very difficult movement.  So the reality sometimes there is no other way to do a case other than extract premolar teeth.  Because 2nd premolars are slightly smaller than 1st premolars, I most often extract the 2nd premolars.

Should you choose clear brackets?

Brackets of clear or white porcelain or plastic are available.  They cost more, break more often, and are more difficult to work with.  Archwires are silver in color anyway. It is our recommendation to use metal brackets, if your vanity can tolerate it.

What about those clear Invisalign aligners?

Invisalign was a great invention.  It is fine for a limited number of easy cases. It is too bad the company is hawking it as a money-maker to general dentists who lack sufficient diagnostic skills to do orthodontics.  In addition, Invisalign has these problems:

  •  It is NOT cheap.  Invisalign treatment will cost a significant amount more than conventional orthodontics.
  • It is NOT conservative. Most Invisalign protocols involve significant grinding on the sides of teeth to generate more space. This can make teeth very sensitive.
  • It is NOT for the majority of cases. It is for cases with no or only slight crowding that do not require extraction of teeth.

Invisalign requires excellent patient cooperation. It is not a passive appliance. If you do not wear the aligners, your treatment will not progress.

 Now, you are armed with some knowledge about orthodontic care!

You may choose my practice for orthodontic treatment, or you may not. But perhaps you can now make a wiser decision in orthodontic treatment. Having straight teeth decreases the chance of gum disease, and will be a great investment in your or your child’s health!

Kim Henry, D.M.D.

July 18, 2007