AVOIDING OVERT OVERTREATMENT

A couple of years ago, a young college student came to our office, clearly distraught. He never had a cavity in his life. While at college, he decided to go to a corporate chain clinic for the free exam and x-rays advertised on TV. Until then he had been going home to his old family dentist. Thirteen cavities were diagnosed by the corporate clinic, with the recommendation of white plastic fillings for all the teeth. I don’t know why, but he ended up in our office for a second opinion. Since he could not obtain a copy of the x-ray series from the chain clinic, I took a very clear set of my own, and looked over them carefully under magnification. The boy had not one cavity in his mouth! He needed nothing but a routine cleaning.

A while back a patient came to us after visiting a large corporate-owned clinic near Washington DC. He had landed a high-paying contract job in the Middle East, and had to get a dental clearance to secure the job. He brought the corporate clinic’s treatment plan with him. It included a series of deep cleaning appointments, fillings and even a crown or two. I examined his mouth carefully, referring to the x-rays taken at this clinic. The verdict? I could find nothing this man needed except a routine cleaning. I guess the corporate clinic operators thought they really had him over a barrel, since he was under a deadline to get dental clearance for the high-paying job.

Just a couple of weeks ago, a young social worker came to our office after visiting a large Atlanta corporate clinic that advertises a lot via radio. This bright young lady already had a Master’s degree and was starting to work on her doctorate. She had beautiful teeth, and had never had a cavity in her life. Yet the clinic had planned her for four quadrants of root planing and EIGHT white plastic fillings. Fortunately, she was suspicious, and sought our opinion before proceeding with the treatment. We found that she had some tartar under her gums, but really needed only a routine cleaning, and no fillings at all.

Because all three of these patients were skeptical, their teeth were saved from unnecessary, even harmful treatment.

dental consumer info

The sad part about overtreatment is not just the money patients spend needlessly. It is the damage to the teeth. Virgin teeth without fillings are a beautiful thing. They are durable and decay resistant. It is one thing to remove a real cavity and put a long-lasting filling where the decay was. It is quite another thing to drill on a tooth free of decay and place a plastic filling that will leak and require replacement in a few years. Every time a tooth is drilled upon, the pulp inside is irritated. With enough treatment, teeth often need root canals and crowns. It often becomes a merry-go-round of one treatment after the other.

Why is inappropriate treatment so common at clinics owned by corporate investors, instead of licensed dentists? Well, for starters, these clinics are usually staffed by young dentists with outlandish student loan debt- often a quarter to a third of a million dollars. The clinics pay them a fairly low commission, and contract with insurance companies to do dental procedures at low fees. This makes it very difficult for young dentist-employees to honestly make a living supporting their families AND pay back their student loans.

Meanwhile, corporate investors who own the clinics typically seek a 20% return on investment. Overhead for dental offices is quite high and 20% profit is hard to achieve, if all staff is paid market wages. Many times, clinic managers (who are not dentists) badger the providers to churn out more dental treatment. A lot is necessary to be scheduled when clinics cut fees 20-30% for insurance companies! Under this pressure, a lot of needless treatment is recommended to patients. At some corporate clinics, dental assistants and office managers actually add treatment so that they can meet the monthly office revenue goals and receive their bonus!

In my experience, overtreatment of patients is fairly rare by independent dentists who own their practices. Dentists like me depend on referrals of new patients by satisfied existing patients, rather than by expensive advertising on radio and TV. To be sure, there may be differences in treatment options presented between honest dentists. Other dentists are far more apt to cut teeth down teeth for porcelain crowns than I am, because the Navy taught me to do do such good silver fillings. Other dentists might be more apt to do bridges on natural teeth rather than implants. These are legitimate treatment differences between dentists. It is a far cry from the blatant fraud perpetrated on patients who have nothing wrong in their mouths!

It is very difficult for the average patient to process what is truthful and what is not in advertising. A good rule is not to believe any advertisements by health professionals broadcast over the airwaves. The promise of free exams and x-rays in a large clinic with expanded late and weekend hours is very tempting, especially to uninsured patients. But judging from patients we encounter, the ultimate cost of letting corporate-owned clinics treat you is very high. You will pay very dearly for that free or discounted exam. After your insurance money is spent, you might have to pay for the treatment out of pocket when something goes wrong!

Incidentally, did you know that ownership of dental offices by corporate investors who are not dentists is actually illegal in Georgia, as well as most other states? Exactly because regulators were afraid of what is presently happening to patients in corporate clinics. How then do all these corporate clinics exist? Corporate investor-owners scam the state regulators by setting a “fake owner dentist” up with a shell corporation, and claim they just “manage” the clinic for the dentist. When in actuality, the official “owner” dentist cannot even access any checking account where funds are deposited from patient payment! Write your Georgia legislature and demand the Georgia Board of Dentistry develop ownership tests, so corporate investors cannot get away with these scams!

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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.