Ah this article put the finger on why I don't trust my 'new dentist':
The operation is just too slick from a business POV. As someone familiar with SaaS or in general this kind of recurring business model, you can sense all the little operational policies and procedures designed to increase your LTV.
It's a well-oiled machine. Without fail, the hygienist recommends cleaning not once every 12 months or even every 6 months, but every 3 months. When pressed on why, eventually they'll admit it's how nice it feels to have clean teeth and how important your smile is - but NOT strictly necessary for health.
This particular dentist also will shut down and take their entire staff to a resort for a week every winter if the team "hit their targets" for the prior year. That's the literal phrase they used to explain the trip. When I asked what those targets were, the person turned bright red.
So dentistry has a trifecta of factors that will encourage dark-patterns: (1) a true health-related reason for going both preventatively and to deal with problems; (2) a cosmetic / vanity-related reason (white teeth), and (3) the air of higher-educated medical authority.
Wrap that all in a lucrative recurring business model and of course it's going to lead to people taking advantage or at least overpaying for what they really need.
Just writing all this out made me realize I shouldn't be going to my current dentist! Thanks OP. :)
Yup. In fact, a great hack is to go to an inexperienced dentist instead of an experienced one for routine work. The reason is that dentists who are fresh out of school are competent enough to do basic cleanings and checkups. But they haven't yet had time to accrete the expensive habits, and the little business optimizations that feed them, that highly-paid professionals often develop. I generally switch dentists every five years or so, and find that cadence works nicely.
(Source: a couple of my close friends are dentists and suggested this strategy.)
Here in Germany it is actually the really old dentists that can be trusted. They were not raised to think business oriented. Though most of them have have retired by now.
My old childhood dentist used to do the absolutely necessary. He just cared about keeping my teeth healthy and not putting me under unnecessary stress. He did not even remove my wisdom teeth. When he retired the new doc would simply maximize the amount of procedures. One routine checkup and he would find ten things that needed to be done.
What had changed? In Germany doctors used to be basically paid from a fixed budged. In 2007 there was a health care reform changing that. Now they would be paid for individual procedures. So obviously doctors would try to do as much profitable procedures as possibles.
The articles misses the target a bit, probably because health care in the US has been run like a business for much longer so it is harder to see the real issue: It is not cultural, it is not some dentists being shady and it can not be fixed by educating dentists. It it the natural result of the incentives that are in place.
If you try to run health care like a business you will necessarily and always produce these issues. And this is not dentist specific. Lot's of unnecessary but profitable surgeries are being performed as well.
The best dentist I ever went to had a picture of his airline pilot wife on the wall - and from how he treated his patients and charged, I got the feeling he worked because he liked to, not because he needed to.
However, if you have a "flat fee" dentist/doctor you could be now encouraging the opposite - do the minimum work necessary to get done with the day. It's hard to legislate "be a caring, honest professional" but we can at least remove some of the incentives to not be.
> However, if you have a "flat fee" dentist/doctor you could be now encouraging the opposite - do the minimum work necessary to get done with the day. It's hard to legislate "be a caring, honest professional" but we can at least remove some of the incentives to not be.
First of all, we know that it does not encourage the opposite, see Germany pre 2007 or any other country where where health care is not run like a business but let's look into it in the abstract:
Humans love helping other humans. The "be a caring, honest professional" part is a product of intrinsic motivation. The idea that it needs to be externally motivated is extremely harmful. That is not how humans work.
Yes, some people get into medicine for the social status, the power or simply money but that is not the majority and we need to a way to filter out those that are full on narcissistic but the vast majority really just wants to help people.
> The best dentist I ever went to had a picture of his airline pilot wife on the wall - and from how he treated his patients and charged, I got the feeling he worked because he liked to, not because he needed to.
You hit the point here. He doesn't need any external drive to do his best, he just needed the opportunity.
It's similar to software developers wanting to write good code. They will strive to do so given the chance and ability even when management discourages and punishes them for that, as is often the case. (Well, "good code" might be subjective but you get the basic idea, humans want to do a good job.)
Yep, the hard part is going to be switching tracks from one to other, which will take an entire career (getting a dentist addicted to money to be satisfied with a moderate income can be hard) - which likely means that the change will come by classifying some "new kind of toothcare professional" that will slowly overtake.
My "really old dentist" drilled a whole straight through 2 teeth and didn't tell me after filling it up... It is just an anecdote (as is your account), but I now prefer a university clinic where young students are taught and most of the time keep working for a time there as well. Up to date techniques and they are not out for the big bucks yet.
Perhaps there is a U-shaped curve with the range being the desirable properties and the domain being years in operation. Young ones can often start with the MBA stuff, and I've experienced MD's who seem like they are about to retire by selling their practice to a whole army of MBA's, but in the meantime they don't just do stuff for the revenue.
So how this worked was that you couldn't just open shop wherever you pleased as a dentist but needed to get a "place". Basic calculation was: we need one dentist per x-people in an area to make sure everyone has access to one. So, as a dentist, you would try to get a slot or probably just take over an existing practice.
I will simplify it a bit but basically there is x-people paying insurance (health insurance is mandatory for nearly everyone) and we calculate how much it costs on average to provide health care for for one insured person (children are mostly insured under their parents so it is more like per family than person) and with that you allocate a budget on what to pay the dentist.
So basically if you were a dentists and you patients rarely ever needed to visit you, you were golden. You were incentivized for keeping them healthy. Sure you might get unlucky and get lot's of patients with very complicated problems but on average it would even out.
Again, I simplified it a lot and am no experts and there have been multiple health care reforms through the years, (actually 2004 is when the new system started) but that is the gist of it.
The health care system has extremely eroded over the years here in Germany. People wait months to see a specialist and life saving operations are postponed constantly. We are on the brink of collapse and that was before covid hit.
All because certain politician were sold on the idea that health care should be run like a business.
Interesting point. For whatever it may be worth, I live in Canada, though I don't believe dental school here is especially less expensive than it is in (say) the US.
Yeah, this seems like questionably consistent advice, especially in this day and age of endless 'maximize your profit' courses. I'm sure there's plenty of things online on how to extract the most value out of your patients that any inexperienced dentist can use.
When I was 21, my dentist recommended removal of my wisdom teeth. I asked why, he said because they are difficult to clean, and so I'd lose them anyway by 30. I switched dentists.
I'm old now, still have those teeth, and they are the healthiest teeth in my mouth.
If you want to keep your teeth,
1. get an electric toothbrush
2. brush for the full 2 minutes, twice a day
3. floss twice a day, gently (overdoing it will erode the teeth)
4. run one of those rubber pointy tools (gently) around the gum line twice a day
Take a look at people 60 and up. Most have false teeth. Do 1..4, your old self will thank you.
There is this idea that the only thing you need for good oral health is to simply do the maintenance. This couldn't be further from the the truth, and an honest dentist will tell you so.
There are plenty of folks that take exceptional care of their teeth, yet still have issues and there are plenty of folks that don't take care of their teeth the way their dentist recommends and still have healthy teeth. Genetics plays a massive role in oral health and this has been known at least since I have been a kid (almost 40 now).
1. Be born (and stay in) the right part of the world, too.
I'm fairly lucky to be in my 40s with all my wisdom teeth intact and zero cavities, in spite of not flossing, never seeing a dentist, and only brushing once a day with a plain toothbrush. That is clearly genetic, since out of my entire immediate family, one sister has had one cavity and that is it for all 6 of us.
But we've always lived in first-world cities with fluoride in the water. My ex-wife had impeccable dental health for a long time until she did a military deployment to Djibouti for 12 months, and came back with 8 cavities. In the 15 years since then, she's never gotten another.
I think this was the only heathcare thing I ever fought with my mom over, in high school. Demanded we get a second opinion. The oral surgeon agreed that my teeth were fine. Still have them 20 years later, still no cavities. It just seemed nuts to me to remove something through surgery that wasn't causing problems.
My favorite "reason" for why they should come out was, "you're more likely to bite your cheeks."
One of my wisdom teeth is laying sideways and I've been told I need to get rid of it for ... twenty years now and still haven't bothered, since the cost of getting rid of it now and when it starts to do whatever horrible thing it's plotting to do is basically the same, I continue to punt.
One of my teeth is currently being resorbed. It has no known cause and is untreatable, eventually resulting in tooth loss. The dentist wanted to preemptively remove it. It could fail tomorrow, or 5 years from now. I opted to do nothing until it does fail. So far, it's been a year and a half.
There is no reason to floss twice daily. This doesn't even really make sense - what would you be flossing out in the morning upon waking?
Flossing once per day is plenty.
You also need not use a 'rubber pointy thing' - proper flossing goes just below the gum line and will get everything you need removed.
Super agree that you should get an electric, though. Heck, I switched from an oral-b to a phillips sonicare and my staining improved enormously, but that's really just cosmetic. ymmv.
It was the last piece in the puzzle (in addition to the toothbrush and flossing and flour) that has kept my teeth fine although I didn't visit the dentist for many years (before last time). This, thanks to their good advice (the dentists where I lived at the time, many years ago)
What techniques are most helpful? I see plenty of armchair mouth experts (I, myself almost spoke up, too), but I'd like to give space to someone who went to school for this stuff.
I got mine out recently in mid 40s. Wish I had done it sooner. Constant minor infections. And every so often the would move and cause a lot of pain, especially in 2020, when it was all arranged then got cancelled for the covid overreaction.
> I've had a dentist comment on how he wished he had so few issues.
Ok, but your anecdote doesn’t really say much. I’ve had a dentist tell me that too, and I intake plenty of sugar, grains, and alcohol. Haven’t had a cavity or other major dental issue in 38 years. I brush twice a day and floss once, and only sporadically see a dentist.
They clean between the teeth and the gums where the gum overlaps the tooth. The evidence is your gums bleed the first time you do it, which is evidence of inflammation. A few days doing it, and the bleeding stops.
You are predicting that gums will bleed, so something that hasn't yet occurred is evidence of inflammation, so keep on doing it until your body adapts to it.
> ...but every 3 months. When pressed on why, eventually they'll admit it's how nice it feels to have clean teeth and how important your smile is - but NOT strictly necessary for health.
Sometimes they can give a proper reason. Like in my example I've got some largish gum pockets around three of my teeth that are getting better but still not great (was a lot worse before they did some deep cleaning 9 months ago, I was seriously worried I had a couple of abscesses, lots of pain, gum swelling, and bleeding), so every 3 months makes sense to check in on them and keep them cleared out enough they can heal better.
Did the hygienist measure your gaps and recommend interdental toothbrush sizes so you can do it yourself regularly? Tepe is a good brand but any really will do as long as you know what size to use. My hygienist measured and wrote sizes down for each gap between teeth.
Fun fact that I’m quite proud of: my father is the reason measuring your pockets is standard of care (he’s a periodontist turned attorney and lecturer). Question any dentist that doesn’t do this as part of cleanings.
They measure my gaps each time, yeah. I had three 6mms that are now two 5mms and a 4mm, and a lot of 4mms and 5mms that are now 3mms. They didn't mention the interdental brushes, but that might be because I have a Waterpik, which they did recommend I use 2-3 times a day, instead of just once, as well as brushing.
My gums also generally feel a lot better now, except for some periodic issues with the two 5mm gap teeth. Like it's pretty obvious to me that they're better. It used to be painful just to lightly brush some of those places that aren't now, and bleeding is a lot less common, and swelling is way down.
The Tepe brushes look interesting though, I might have to give those a try.
My pockets got better after I started using a WaterPik with a special attachment called the "Pik Pocket". I use warm water with a little splash of hydrogen peroxide and irrigate them all.
Caveat: I have a couple of “Cadillac” dental insurance plans due to great employee benefit packages for both me and my wife. So they cover quite a bit.
I just tell the hygienist before I get in the chair that if my insurance doesn’t cover it, I won’t be doing it, and don’t even suggest it. Generally that stops the upselling.
my dental group actually calls/emails me on a regular basis to get me to come give them that sweet, sweet free insurance money. but note for instance that cavities and fillings are prone to being overdiagnosed for the sake of income, not patient outcome. glasses are regularly overprescribed for the same reason. patients really need to understand the incentives and motivations of medical professionals to make the best decisions for themselves.
dentistry, optometry, therapy, veterinary, and even primary care all are vulnerable to the "recurring revenue" model. it's reasonable to be skeptical of their motivations even as we go to them for help and care. that's why patients should view medical professionals as an informed but biased opinion, not an authority. the patient needs to become knowledgeable about their own malady to make the best medical decisions they can, and it's part of the professional's job to aid that journey, not to make the decisions for the patient. that's also why patients need to see multiple professionals to triangulate their best option, rather than getting locked in to a single care provider. monopoly forces are antithetical to this process.
the shaman strategy is alive and well, and will be for many centuries/millenia to come (in other words, we're not uniquely advanced in the history of humanity).
Optometry at least you can track it (if you actually do need and use glasses) because the differences should be noticeable on the prescription.
What does happen is that if you buy a new pair even with the same exact prescription, the fact that it's new and clean and not bent in anyway will make it look much clearer. So that can trick people into thinking they need yearly new glasses.
A good optometrist will tell you when your prescription has stopped changing and when they expect it to start changing again (usually in your 40s).
sure, but wearing glasses also weakens your eye muscles. we're living, dynamic, nonlinear, and stochastic systems, not automata with orthogonal settings that we can tweak simply. glasses can actually make the problem worse (i've personally experienced this in my younger, naiver days[0]). optometrists don't question orthodoxy because doing so could threaten profits.
note, that's not to advocate the other extreme of never trusting anyone about anything, but every decision is a trade-off and has drawbacks. the visual acuity afforded by glasses should clearly outweigh the downsides, rather than outsourcing your brain to a hammer-wielding optometrist.
[0]: i still have dry-eye from an eye infection that was likely caused by contacts. that was actually the impetus for getting rid of corrective lenses altogether and the subsequent realization that i didn't need them in the first place.
I hate going to the dentist for this reason. It used to be they cleaned your teeth fixed any issues, come back in 6 mos. Now, I feel like they make up issues, they have cleaning or super cleaning - how about just do the damn cleaning, etc…
A couple years ago I had one recommend putting on a crown on a back molar. I asked why b/c I had no pain and they couldn’t really explain. Every other dentist I’ve been to since never brought it up again.
At the moment, I go to a new dentist every 6 mos. to a year because I can’t find one that doesn’t feel like one step above a used car salesman.
Final note, get a SonicCare. Dental friend (sadly in another state) says those things changed dentistry/brushing/teeth cleanliness.
Sonicare specifically, or electric toothbrushes in general? I have an old Braun electric toothbrush and it seems to work well, but I could switch brands next time.
Throwaway because I run a large dental software company.
Dentistry is practiced as a business focused on maximizing revenue. Dentists are routinely coached to deploy sales tactics to increase their treatment acceptance beyond what is needed. If you walk into a dental office, you need to protect yourself from being abused. A second opinion unfortunately puts you in the same position, but now with a new dentist who will play into the narrative of only needing to monitor your condition for a while.
The business of dentistry is unfortunately antithetical to conservative treatment, which is almost always in the interest of the patient, because it results in significantly lower patient lifetime value.
I've told this story here before, but I grew up with very health-illiterate parents, who were very "old school" in the sense that if anyone in a white coat said something, it was gospel. Doctor, dentist, nurse, whatever (curiously they had and still have extremely negative opinions of medical paraprofessionals like PAs and NPs).
Anyway, I was around 15 or 16 and had always had perfect dental checkups. One day I had another routine checkup, but now suddenly I had to get nine fillings. I asked my parents to get a second opinion, but they refused and I got the fillings. In a move that would surprise absolutely nobody, that dentist sold the practice a few months later. I'm 100% confident that he was just goosing his revenue to increase the sales price, or make it a more attractive acquisition based on the revenue trend. That was around 20 years ago and I haven't had a single other dental issue beyond getting my wisdom teeth removed a few years later.
I think dental care is super important, but dentists are concerned primarily with maximizing their revenue in a way that would get most physicians' licenses revoked.
Now I'm grateful for my parents' choice of dentist. She worked out of a small office attached to the back of her home, and had family members as office staff. This is in the 90's in a very posh suburb of a major city, not some backwater a long time ago. Anyways, that dentist always had unique advice, she told me that if I were going to only do either brushing or flossing, that I should do the flossing and skip the brushing. Doing both is better, but she observed that many people skip flossing too much. She also said that toothpaste was largely superficial, and good brushing without toothpaste was just as good. She also would spend lots of time literally demonstrating good brushing technique and explaining why to do it that way. I also have some slightly crooked teeth, she said to push them with my tongue instead of getting braces. When I grew up, before going to college, she advised me that I don't really need to see a dentist regularly as an adult, and my teeth will be alright as long as I continue brushing and flossing. Cool somewhat hippy dentist was right on all accounts, and I've had good dental health ever since. Another anecdote: she would trade dental services for my dad fixing her various dental machines and equipment. Not sure how that arrangement came about, my dad wasn't really qualified or anything, he was just pretty handy and usually managed to fix things more than break them. And it wasn't disguised charity or anything, we had no issues paying. Pretty cool dentist.
I've heard the "flossing more important than brushing" from a number of sources, and it makes sense; it can be a pain but it's literally getting at areas that your lips and tongue can't.
Interesting. A similar thing happened to me. After a lifetime of zero cavities, the dentist I'd seen a few times for cleanings announces that my luck has run out -- I've got several cavities. I declined any work, but I was concerned. Shortly after that I ended up moving to a different state and it was about year before I got back in to a new dentist. I was dreading it since I figured he'd tell me I've got cavities. Nope -- said everything looks great, see you in 6 months!
Worse happened to me. I had no cavities until the age of 36. Then I apparently got two. New dentist. I went for a second opinion and a second new dentist confirmed it, but who knows. I got the fillings. Within six weeks, one of the teeth broke in half around the filling and the guy was trying to give me an emergency root canal. I ended up having to have it pulled. The other one broke in half a few months later, another emergency surgery. That time, I went in and I'm pretty sure he worked on me drunk.
I haven't tried to sue the guy, but I think seriously about firebombing his office every time I drive by it.
There must be options in between suing him and firebombing his office. Seriously, think about folks coming in after you. Try to at least file a complaint, or give a bad review some place.
A few years ago, a friend of my cousin became a licensed dentist here in Sweden. My cousin had to remove a tooth and his friend gave him, I assume, a lower price because they're friends...
He removed a tooth alright, but the wrong one (on the wrong side). And apparently my cousin just assumed he worked on fixing something else, realising the mistake way too late.
I asked my cousin if he considered suing but he didn't want to do that because they're friends...
Reminds me of people getting "THIS LEG" tattooed on the leg to be removed, perhaps something similar with a stick on tooth decoration could be worth it.
I used to live in Spain, and I remember being shocked when my doctor told me how common it was for people to have the wrong leg or kidney removed there. She was originally American, and implied there was a strong inverse correlation between the cap on malpractice damages and the number of incorrect organs/appendages detached. Honestly, although the American medical system is the pits, it gave me a better opinion of American tort law and made me believe that some of the seemingly superficial lawsuits in this country serve a better purpose of keeping the otherwise wild-west medical system in check.
[edit] just as a side note, I've noticed a strong trend here among people who also never "had a cavity" in another country until they were in the US
There was some pretty significant pressure against having doctors use checklists (like pilots have) - but it has also decreased errors significantly (both in aviation and in the medical field).
They also act as a form of documentation; I highly recommend checklists whenever I can.
> curiously they had and still have extremely negative opinions of medical paraprofessionals like PAs and NPs
This isn't entirely unfounded. There are real concerns over replacing MDs with mid-levels with much less training. The AMA is significantly to blame for the switch, but as a general rule I won't see PA/NPs for anything beyond prescription refills or something like that.
But that routine care is a good case for PAs/NPs. Pulling blood once and year and refilling my inhaler doesn’t require any speciality knowledge that only an MD would have. Most people shouldn’t have any reason to avoid one for their annual check or treating a run-of-the-mill illness.
Even that is arguable; I'd rather see an MD for an annual physical. It seems like a routine thing to people not in the medical field, but there are a ton of little things that are checked and could be caught early. I'd rather have an actual doctor performing it.
A few years ago I went for an initial screening to 3 different dentists and was shocked by the gap in suggested treatments. One wanted to do major work on like 11-12 teeth, another just fillings on 2. It made me lose all trust in American dentistry and I ended up going to get work done at a dental school instead because I knew it would be supervised by professors who are not optimizing for their bottom line.
I have a very expensive surgery coming up on Wednesday next week. My original dentist didn't even see anything wrong with the tooth. New dentist saw a deep canal but did a deep cleaning (f-ing painful!), and told me to wait a few months to see if it heals. I insisted on seeing a periodontist sooner. Tooth must come out. Sought 2nd opinion - she is convicned two teeth must come out. Then changed her mind. Now telling me bone graft material in the US is superior and I'd better get it done here than originally planned in a few months in Europe (thus saving a few thousand dollars and postponing some suffering so I can go on a vacation).
Getting a third opinion the night before the surgery and literally don't know what I am going to do with it.
What even the F.
When I moved to the States (Oregon) for a few years, I had to hunt for a number of services, with dentistry being one of them. I worked for a pretty large SaaS private (at the time) company, so the perks were plentiful, but most importantly, private insurance was up there in terms of quality.
Now, I'm originally from Canada, and without getting into the differences in healthcare between the two countries, but the amount of discrepancies I also received, let alone front-desk saying "oh my goodness, your insurance is incredibly good!", usually always resulted in the dentist informing me that I have 12 cavities.
The sad thing was in shopping around, and going to a number of different places to try them out, all ranged between 12 and 6 cavities, some even suggesting major dental work (2 crowns) required. I even went to 'work colleagues' recommended ones. All gave shocking details about my teeth.
Depressed, and annoyed, I went back to Canada, saw my dentist (and got a second opinion from a 3rd-party as an A/B test), and had 0 cavities to report. The second opinion stated I also had 0 (with maybe 1 on the way, and if I wanted, could opt to have it addressed now, but not the end of the world).
In the end it was cheaper (in almost every way, sadly) to see the Dentist on trips back to Canada, instead of opting for what would effectively have been the decimation of my teeth in the States.
I remember a Swedish consumer advocacy show on public TV (Plus with Sverker Olofsson for all the Swedes out there) did this test some time in the early 00's, sending the same person to like 10 different dentists, including also public health care ones that don't have a profit motive, and they all had different results.
This. I brought my kid to check for his open-bite problem, seen 6 different orthodontists and oral surgeons, everyone has a different opinion: from removing 7 teeth then do a jaw surgery(a 70K expense) to using some rubber bands to pull down the front teeth and observe what happens next($4000), each one has a different opinion.
All dentists running practice are suggesting way more expensive approaches, the last and cheapest one is actually from a dentistry university, where the professor seems more interested in studying the case instead of doing a quick surgery with huge costs.
Is it just me or do dentists rarely if ever suggest that their adult patients change their diet to avoid dental caries? They probably still tell children "don't eat candy", but since I reached adulthood I don't think a dentist ever told me suggested that the reason I needed so many cavities drilled was because I was feeding bacteria in my mouth.
If my experience is as ubiquitous as I suspect, there seems to be a perverse incentive among dentists to allow adults to ruin their own teeth. It's convenient because most people know extremely little about dental health beyond brushing and flossing. A minor carie on the enamel doesn't necessarily progress further than surface damage, and in some cases can even be reversed. Instead of saving the patient time and money by waiting for further progression of a carie, many dentists see the tiniest surface divot as an opportunity to drill n' fill. A more appropriate response would be to suggest the patient eat an appropriate diet that doesn't feed carie-causing bacteria and to come back in 6 months to a year for a follow-up; if the carie is visibly worse, then now it's time to consider drilling.
In defense of dentists, I imagine so few adult patients are compliant with suggestions of lifestyle changes that they figure it's hopeless and they might as well be the ones to cash in on cavities rather than some other dentist. Everyone hates going to them and they know they can't win.
A dentist once told me that it's worse for my teeth to sip a soda or a coffee slowly over several hours than to chug it all at once. I wonder if it was suggested because patients might actually do that, compared to not drinking soda or coffee at all.
(I might drink coffee slightly faster than I used to. I do not drink soda. I'm fine with stains but not unnecessary tooth decay.)
I've been told that drinking it via a straw is better on your teeth because the straw deposits it directly into your throat and doesn't swish it around your teeth, but in any case I suspect doctors and dentists have stopped telling people to change their diets because people just don't.
It would be hilarious if this turns out to be true. My wife eats slowly, has some dental problems.
I eat extremely fast, have been criticized my whole childhood because of how fast I eat (and drink, but nowdays I drink only water).
> If my experience is as ubiquitous as I suspect, there seems to be a perverse incentive among dentists to allow adults to ruin their own teeth.
If you read the thread, some dentists will perform needless work on healthy teeth to make money, so I doubt there’s an incentive to let adults ruin their teeth when you can just lie and say they need the work anyways.
Go to the dentist in France and they will warn you that without sealants you might get cavities. In the US most dentist don't even attempt to offer to adults the simple and cheap treatment that prevents 80% of cavaties.
I've gone to my current dentist for years and he's always extremely reluctant to even do fillings (last time he gave me a speech about how you can't replace what "God gave you" so you should just monitor it or so.) I think there are some dentists that legitimately care.
EDIT: Mine is actually in a very wealthy neighborhood and the lady who runs the practice (I think that's how it works?) has a reputation for buying state-of-the art tech.
This. I come from a family of dentists and they are very hesitant to drill unless absolutely necessary. Their rationale as I understand it is that all fillings, crowns, bridges, etc fail eventually. That anytime you attach something to a tooth you add a failure point and potential for infection.
The problem is their businesses can’t compete with the ones that play the insurance game. Insurance reimbursement rates haven’t kept up with overhead and so conservative dentistry is losing marketshare to ones willing to push treatment. We know multiple dentists that have filed bankruptcy in the last couple years.
Keep in mind that many people are very reluctant to pay out of pocket for dentistry. Until insurance reimbursement rates favor conservative dentistry, nothing will change. More responsible dentists will lose their practices or turn to over treatment.
Maybe the HN crowd wisdom has some ideas on how we can improve this situation.
> Maybe the HN crowd wisdom has some ideas on how we can improve this situation.
HMO / Capitation dentistry is the obvious answer here, where your dentist gets paid X per patient per year, to focus on preventive instead of pushing unnecessary care.
It’s really hard to implement in the US though because people push for a lot of unnecessary stuff.
Well sure, but in the universe where capitation rules the world, we have people clamoring for services that they say they need, but professionals refuse to provide.
And there are probably HN threads there explaining why we need to go to a fee-for-service model.
>It’s really hard to implement in the US though because people push for a lot of unnecessary stuff.
"Unnecessary" is in the eye of the beholder to a certain degree. Extracting a molar is pretty cheap. Root canals, implants, and crowns much less so. But, depending upon the circumstances, more expensive procedures may make sense.
There’s a dentist near where I live in a wealthy neighborhood that I went to once and was great. Problem is, she’s expensive and doesn’t take insurance. She doesn’t need to push anything extra because everything is already priced where she needs it to be. Obviously that won’t work generally, but something to think about.
Basically you go to several dentists and chose the conservative one - it is not that hard. Yeah, most of them are in so so neighbouhoods and have outdated equipment, but you wanted to have less intervention in any case, right?
Ugh, yeah… it’s so frustrating that as a consumer you can’t tell for certain whether your teeth need to be drilled or not. I’d so much rather pay some bullshit dentist-needs-an-audi fee, rather than pay to needlessly destroy the structural integrity of my teeth so they can make a buck.
Same, we have had the same dentist for over 15 years and I now drive across town to visit him. Trustworthy and reluctant to do any care unless required. Still tells me I need to floss.
Yeah; the ones who treat conservatively are gold. I'm still looking for one in my current location over ones who are aggressive in pushing additional treatments and things.
Incentives guide everything in medicine and it's really unfortunate. Even the best meaning doctors get pushed in that direction. See x patients a day for y minutes. X goes up 10% and y goes down 10% every year. My brother is in his residency and in one rotation was asked to see 35 patients a day at a clinic. Impossible to do anything but the most cursory work. Health advocacy is becoming a bigger thing in the United States and it will only continue. People need to remember that medicine is now a consumer good, with all of the pitfalls that entails.
> The business of dentistry is unfortunately antithetical to conservative treatment, which is almost always in the interest of the patient, because it results in significantly lower patient lifetime value.
Isn't this the case with other healthcare providers too, and not necessarily just dentists? For example, physicians will regularly make you wait at least 15 minutes—even in an empty office—so they can bill insurance for that extra time. They'll bill patients for "emotional/grief counseling" and lots of other unrelated charge codes as well. I've seen from firsthand experience how doctors will exploit patients and try to milk as much money as they can from them, rather than prioritizing their wellbeing and health.
Yes, principal-agent problems in healthcare are pervasive.
But while medical upcoding fleeces patients, providers often feel it victimless because the procedures are almost always diagnostic and confused providers believe them to be paid by some third party (insurance, the state, but surely not the patient).
Dentists, in contrast, don't just upcode diagnostics, they systematically over treat their patients.
> Dentistry is practiced as a business focused on maximizing revenue.
All medicine is practiced as a revenue maximizing business (or it would cease as an ongoing concern). It's easier to see this in dentistry since at some early point in the US the field/cartel opted out of many of the omnibus health payment plans that otherwise obfuscate value chains. Aside from the notable exception of tobacco cessation, disease prevention gets short shrift compared to intervention. This is slowly changing but has started from a tremendous deficit.
This is a truth about corporate dentistry, and it common in family practices but less so.
I used to know a few dentists. One was a conservative, family dentist with a small home office in a small home (and a mountain of savings). He had a good rep bc he earned it. The other two had a bit more extravagant lives, and they earned it through specialization (and in my opinion, probably a little bit of this article).
What consumers should be most concerned about is the end of family practices, and the start of corporate 1800-DENTIST/Supercuts for dentists. Issues like this article are the norm, and instead of a local dentist to seek resolution with, you’re doing the equivalent of filing a Jira ticket with a faceless insurance conglomerate.
This is the trend the industry is going bc of the costs and difficulty of owning a practice. If you can, I recommend finding a young dentist who has recently bought into a home office partnership, and stick with them until corporate dentistry takes over. It is the only way to consistently avoid situations like this article.
About 90% of the treatment I had was in the year or two after my local dentist was bought by a large, publicly listed dentist corp. (This is in New Zealand.) I've switched back to another local dentist and no treatment needed in the decade since. Although I guess all those crowns I got will need replacing eventually.
Well it's only anecdotical of course, but I had a similar experience a couple of years ago that made me very confused about dentistry in general.
At the time a had a small tooth ache so I was planning to visit a dentist to check it. I was living in Switzerland, where dentist costs are very high, but I was about to go on holiday to Tenerife, where prices are much lower. So I checked on the Internet and chose the dentist with the best reviews near my holiday resort.
When I was there and had explained my problem, the dentist said he'd like to do a full check of my teeth. He did that with a little camera so I could see my teeth on a screen as well. Next he went past all my fillings. I had quite a few of them, and for every one of them his comment was the same: 'decay'. He said they were old, or didn't fit properly, so around the edges decay had started. And indeed the image on the screen showed some brown edges.
In the end he offered to replace all of them with some modern alternative. The treatment would cost a couple of thousand euro and would take my entire holiday week.
I didn't entirely trust him so I said I needed some time to think about it. Back in Switzerland I went to my usual dentist. I didn't tell him about the Tenerife episode but just explained about my complaint and asked him to check. He concluded that there was not really any problem, it might be my gum was infected and this gave me some pain. Then I told him the diagnose of his colleague in Tenerife. I expected that he would be shocked but he wasn't: he asked how much the guy was charging and just said it wasn't a bad price.
I then told the story to a friend whose both parents were dentists. He wasn't surprised either and he explained like this: he said dentists were like car mechanics. When a car mechanic is checking your engine and some parts were a bit worn out, some would say they should be replaced, but others would say they are still working so let's only replace them when they break.
It's 5 years later and all those 'decayed' fillings haven't given me any problem so far. But maybe I was just lucky? I'm completely confused now.
Yep, sounds familiar. When I was a kid I broke one of my front teeth in half my dentist glued it back on saying it would probably not last too long but worth a try anyway. Many years later it broke off again. I didn't have dentist at the time (just moved) and did some shopping around (most had waiting lists). The first dentist said it was absolutely impossible to glue the bit back on, and offered to replace my tooth with a fake one entirely. Would cost only EUR 1500 or so.
I called around a bit more, and then another dentist said she had no time but she was on duty that night in the ER. Said I could just pop by in the hospital somewhere after midnight and she would have a look. In five minutes my tooth was glued together again. I paid 40 euro in cash and that was that.
I used to get my dental work done at a student clinic, so it was often dental students doing minor procedures supervised by much more experienced faculty. I remember overhearing one explain to a student that different people and mouths have a different standard of what's acceptable. Someone who meticulously brushes and flosses and spends top dollar fixing every problem as soon as it comes up is likely to want a procedure like you described. Someone else who barely has any dental hygiene and a mouth full of fillings and gingivitis would be given all necessary care, but not necessarily given an exhaustive touch-up if the dentist feels they'll just be back for the same thing in a few years and not get any substantive lasting benefit from it.
I don't know whether this is a generally-held attitude in the profession.
I've been quite lucky with my current dentist since she's not a fan of replacing fillings. I have two old silver amalgam ones and I did ask her about it and she said she'd only do that in like an obvious case where it was freely wiggling or moving but otherwise they should be good for me for the rest of my life. I'm glad she's not one of those dentists that sees everything as a problem. Like when any potential carries were visible on the x-ray she'd usually wait until the next time to do another x-ray then see if it worsened before she went and drilled them out and filled them.
Dentists are a lot like software developers - they're not interchangeable. Just like if you ask two software developers what needs to be done to solve a problem you're going to get at least two different answers, the same is true for dentistry. Actually it's true of any professional service. We all have our biases for risk, we all have biases for wanting work - we all have biases. Those biases will manifest themselves in our recommendations for a course of action. That's why they say to get a second opinion. It's not just to assess whether the first opinion is off-base, it's to get a better assessment as a non-expert as to what you're up against and what course of action you should take.
For what it's worth - a friend of mine is a dentist and he mentioned once that white fillings (the ones that are set with an UV light) start to shrink after 5 years. On the other hand, silver filling will do the same after 10-15 years and at a slower rate. Whether this shrinkage will lead to problems is a separate question.
This is where review sites are starting to help. There's a dentist where I used to live who has dozens of reviews, all mentioning that she diagnosed them with microcavities, which couldn't be confirmed by those who got a second opinion. If you have a full blown cavity, you're going to notice but microcavities? You have to take your dentist's word for it or be sure to get a second opinion and hope at least one of them are honest and competent.
Just in the spirit of sharing, microcavities are in many/most cases treatable with a hydroxyapatite toothpaste. This is true of some larger caries as well.
It does help, but these guys know what they are doing.
My dad had a benefit fund through his union and because his dentist knew how to milk the program, he ended up with a lot of unpleasant and unnecessary dental work. You see it a lot with telephone company employees, fire fighters, etc.
Your friend was quite right. It is quite a bit like replacing aging parts in your car. You may have to eventually replace all your fillings. But you don't know for sure, or when. And it's very unlikely that all of them will fail at the same time.
So, unless a filling is already on the verge of failing, replacing them is mostly a matter of personal preference and scheduling.
It doesn’t undermine the necessity of modern dentistry because there are times you really do need a dentist. If you travel to poor countries where people don’t have access to dentistry you’ll notice that by 30s or 40s they’re missing a lot of their teeth.
The "little camera with screen" immediately jumped out as "designed to get the customer to pony up the money right now" - and I've seen similar things with (as others have mentioned) auto maintenance; and if you know something about it the fact that they bring it out unasked for is a huge red flag (the one I've seen is comparing motor oil from the dipstick with new motor oil and saying it clearly needs to be changed, along with the filter and any number of other things they bring up).
Unfortunately the economics are firmly in favor of replacing things early even if not yet necessary. This is the same for car mechanics or dentists. There is no money to be made in delaying procedures.
I had a similar story but tend to view it more generously.
I am based in the UK, but ended up seeing dentists in Spain and Dubai who were both alarmed by stuff that the UK dentist was letting slide. Maintenece issues similar to yours.
I ended up having most of my fillings replaced at half the cost of the UK work, and have had a problem free 2/3 years.
You pays your money and takes your chances, but I prefer the approach of jumping on any issues early in my ear against too many sweets and fizzy drinks!
the problem with this is also that given dentist has huge motivation to replace as much as he can and make big fuss over little. I mean it pays his bills/rooftop, some mortgages and few vacations on top of other costs... did I mention costs?
they are not more or less moral than rest of population, spread is the same as in all other professions, so experience vary
But this is not necessarily a matter of the dentist being greedy (though it no doubt can be). Anyone who has had a toothache on a Friday evening, knows how long it can be until Monday morning when you can get into see the dentist. A dentist could just be eager to avoid such an agonizing experience for the patient.
He was offering to replace all my fillings, about 9 in total. So not just the one(s) that might cause my (slight) pain. In fact he wasn't even mentioning my complaint anymore even though I told him initially that this was the reason I wanted him to check.
My wisdom teeth grew in about 15 years ago and have sat comfortably behind my molars since.
I saw a new dentist for a routine cleaning “intro package” where she suggested that I have the wisdom teeth removed. I asked her why should I have a surgery for this since I never had problems with them. She said it was a good idea because they were “more likely to develop a cavity” because they are farther back and harder to brush.
So basically she was pushing me pay thousands of dollars to have a serious surgery to avoid the risk of developing a cavity because I might not know how to brush teeth that I have had for 15 years and never had a cavity on.
I wonder how many people just decide “guess I need this surgery”
> So basically she was pushing me pay thousands of dollars to have a serious surgery to avoid the risk of developing a cavity because I might not know how to brush teeth that I have had for 15 years and never had a cavity on
I went to the doctors once for a mild injury, one side of my palm was somewhat numb.
Despite informing me it wasn't very worrisome, they decided a I needed to be referred to a physical therapist, who then tried to put my hand in a cast and set up a dozen extra appointments for an injury that healed the week after the first. Since them I just haven't bothered seeing a doctor unless I feel like I'm immediate or near immediate danger.
> surgery to avoid the risk of developing a cavity because I might not know how to brush teeth that I have had for 15 years and never had a cavity on
That's not because you don't know how to brush teeth, it's because it is physically hard to reach them. Sometimes even impossible, because part of tooth is hidden beneath gum.
Not quite true; sometimes, if an infection develops (even without a cavity, just because food got caught in the gums) it can be significantly more painful to deal with than getting it taken care of when they're healthy.
Of my 4 wisdom teeth, I got 2 removed for that reason. They got infected at least once per year un my twenties and it was really painful. Doctor never recommended to do it, but did tell me "if you feel like it's too annoying, we can remove them". I was the one asking after a holiday completely ruined (and no pharmacy available). So 2 it is.
Now, all good with the other 2,however the new dentist suggested removing them because those are a little bit extruded (they have been this way for a long time). Looks like I need a new dentist
Sure - it depends on the case, and that’s entirely my point. If it hasn’t erupted but still is, it may move teeth. If it has partially erupted it may be harder to clean, etc. My point is blanket “don’t worry until it’s infected” isn’t quite right either.
I went to a corporate dental practice in my early 20's and they showed me via an x-ray that my wisdom teeth were practically horizontal and growing forward rather than upward. But the prognosis was that they would inevitably get infected at some super inconvenient moment. By whose definition of inconvenient though? There was, 10 years later, an infection that I chose not to ignore (it was clearly an infection), and I had the teeth extracted at that time. It was a hassle, it had to be dealt with promptly, but it was dealt with.
I often wonder about this, because they made me remove mine due to "risk of infection". But afterwards I now get infections there if I get food stuck in the pocket left behind and can't get to a water pik soon enough.
Interesting, I did have to do two separate surgeries because my first got botched (I was a ten out of ten in terms of hardness according to them). Had some residual nerve damage...
Is it actually possible? I had dry sockets infected and it was equivalent to going through surgery again, except for the whole day. Had it fixed the next day.
This is actually the standard principle in german dental practices. Every practice i visited for the last 15 years recommended to remove all wisdom teeth asap because they will soon develop a cavity. Nothing happened in all those 15 years. I only get angry every time i visit a dentist and hear the same bullshit again and again.
Near the beginning of the pandemic, I had a pretty bad toothache spring up out of basically nowhere. Bad enough that sleeping was difficult and eating was impossible. I went to see a dental surgeon (I forget the proper name for this) and he told me I needed a root canal, and backed it up with X-rays. It made sense, I had trouble with this tooth before and a previous dentist told me that a root canal and crown on this tooth, while not strictly necessary at the time, would probably have to be done eventually.
The root canal itself was quick, relatively painless, and not super expensive after insurance. But he couldn't do a crown, apparently that's only a dentist thing. Since my previous dentist closed his office, I asked for a recommendation and he gave me a referral.
The referred dentist did the crown just fine but the price gave me sticker shock: about 4x as much as the root canal itself, after insurance! It basically wiped out my HSA account for the year. When I went back for a general checkup and cleaning, the same dentist said they found SEVEN cavities. Which was a little mind-blowing since in the decade previous, my old dentist only filled ONE cavity and always complimented me on the state of my teeth.
I asked how much it would cost out-of-pocket to address the cavities and they gave a number somewhat north of $200. Oh, that's not so bad to have a bunch of cavities filled. Oh sorry, nope, that's the price PER CAVITY. I asked what I was doing wrong because I _had_ been flossing and brushing every day and got a very hand-wavy answer. I was in a literal state of shock so made an excuse about my schedule being full for the next couple weeks and beat a hasty retreat. After the root canal and crown, I literally couldn't afford to have seven cavities filled.
Fast forward a year and I finally find another dentist for a cleaning and evaluation and to tackle at least the worst of those seven cavities. You want to know how many cavities he found? None. None at all.
I had fillings that failed and three of my teeth needed crowns (they really did). I was quoted $2500 per crown. My insurance only covered up to $1000 per year and I didn't have a great job at the time, so I was like "well, no way I can afford $6500" and did nothing.
Eventually the teeth got so bad they had to be removed, and had to get two bridges put in. That was quoted at $6k apiece. At that point I did have a good job again and could afford it, but yeah, that hurt.
Since then one of the teeth in the bridge had to have a root canal, and then the top part of the tooth cracked when the root canal was checked, and so now I need to replace the anchor teeth in one bridge to 2 implants. I was quoted $7k for those (that's one of the cheaper quotes, I've also been quoted over $10k), not including a new bridge that will have to be made, which will be another ~$6k.
I've put that off for three years now (even had a scheduled surgery to start the process I ended up cancelling). My bridge just has a good amount of temporary cement over that cracked tooth, which has oddly stayed in place the whole pandemic. Eventually I'll have to get it done, but I'm putting it off as long as possible.
If I had somehow figured out how to get those crowns in the first place, I might have saved all this grief and extra expense after. I'm up to 3 removed teeth and 4 teeth stripped of their enamel to become anchor teeth to put the two bridges on, which can never just be 'normal teeth' again.
I've also since heard that some places have machines to 3D print crowns onsite and can do it for as little as $300 each. I wish I knew that was a thing before I decided I was too poor to afford proper dental care.
I think what you're referring to in your last paragraph is a CEREC crown, but it's not always cheaper. In my case, my insurance covers a lab-made crown with a $100 copay. It takes a few days to be made, so it's slightly inconvenient. Same-day CEREC crowns aren't covered by my insurance, and cost around $500-$800 at the dentists I went to.
I discovered this last year when I went to a new dentist and they recommended two CEREC crowns and a laser gum cleaning at a total cost of around $2000. This was surprising, because I thought my dental insurance was pretty good. Turns out, it is: the dentist was just electing to use more expensive methods that weren't covered by insurance and failed to tell me about the options. I did some research later and found that the laser cleaning was not demonstrably better than the traditional approach in terms of outcomes (though I think the gums are supposed to heal faster) and was not endorsed by the periodontist professional society. I saw some sources which said that the same-day CEREC crown is actually worse than the lab-made crown in terms of fit and durability.
My wife has a similar story. She had a decent dentist for a while but after a botched crown install she was dissatisfied with the response and started looking for a new dentist. Found one that had a nice modern practice. New dentist said she had NINE cavities. She may have had one cavity in the prior 10 years at most.
This immediately caused suspicion. So we started looking for a second opinion. We got a referral from a friend to a dentist that was more conservative. So she made and appointment with him and wouldn't ya know, ZERO cavities. Not even any "watch" areas.
Turns out this conservative dentist used to teach dentistry at the local state university and actually taught the overtreatment dentist. His response when he found out who said she had 9 cavities was "he was a very ambitious student".
We've been going to him for 15 years now and she hasn't had a single cavity, and he fixed her crown perfectly.
>cost out-of-pocket to address the cavities and they gave a number somewhat north of $200
Sorry for the all caps, but YOU HAVE TO NEGOTIATE PRICES! $200+ per filling is an ASKING PRICE. You counteroffer at $75/per filling. Maybe meet at $90/each.
IF YOU DO NOT NEGOTIATE PRICES YOU WILL BE CHEATED!
Not asking directly to you, but in these cases is there (depending of the country) a way to make this kind of malpractice stop ? Organization to which to report the dentist ?
It's not yet considered malpractice. There is usually a standard of care, but that is not a clearly written standard. It's more like, "we think it is up to standard or not" in each case. I'm not a dentist but this is the way state boards work in my field (veterinary medicine) which is similar. Naturally they are more worried about practitioners who overlook problems than practitioners who are overly cautious.
Malpractice would be if you had no evidence of a caries (exploratory, radiographic or other test) and you recommended a procedure anyway. That may have been the case, but usually they have varying opinions of whether a particular lucency on an x-ray representes a caries, or whether it should be filled. Or there is also a machine that is used to detect caries that are not always radiographically evident. So your dentist probably could claim it was there but other dentists wouldn't recommend filling until there was more evidence of a problem.
Until the governing bodies or associations dictate what the go/no-go criteria are for filling, the dentists will have wide leeway to convince you either way.
If you think this is bad, wait till you hear about [insert field of medicine here]!
In all seriousness, fraud is rampant, and cash pay or low regulation fields like dentistry can easily take advantage of patients and their health literacy.
In ophthalmology, you hear of “laser” cataract surgery, “floaterectomies”, telling patients they need cataract surgery well before they are symptomatic, dry eye treatments.
Hell, in cardiology there have been multiple cases of fraud uncovered where doctors were putting pacemakers and defibrillators in people that didn’t even need them!
Maybe I’m jaded, but when there exists such a profit incentive, we as healthcare providers struggle to “do no harm”. I’m lucky to be surrounded by mentors and other doctors that try and exemplify the moral behavior patients expect in healthcare, but imagine if I had a mentor early on like Dr Lund in the article..
I am especially skeptical of offerings that deal with therapy and the massive advertising campaign some companies like betterhelp. Improvement from therapy is not something that’s easily measurable and I’ve know a few therapists (not psychologists) and their coursework from reputable universities absolutely shocked me in its lack of scientific rigor. I have no doubt there are wonderful and competent folks working at online therapy shops, and I have benefited tremendously from an in person psychologist and everyone benefits from mental health resources being available, but online therapy and the therapists and the bit I know about their studies scares me.
> "Improvement from therapy is not something that’s easily measurable"
Is it not? I have commented before about the work of Dr David Burns[1], and one thing he drills over and over is that therapists need to start measuring their work, and it is easy, and they don't because they either don't want to hear that they are doing a bad job or they depend on their clients for long term income and so aren't incentivised to want improvement. He endorses a mood survey[2] which the patient/client fills in at the start and end of every session. If the patient self-reports "I feel 5/5 hopeless" and two sessions later they report "I feel 2/5 hopeless", isn't that a measurable improvment? if instead they say "I still feel 5/5 hopeless" isnt' that a measurable lack of improvment?
It isn't an objective quantification but if the reason for seeking help is self-reported bad feelings, and afterwards the bad feelings are reduced or gone, the evidence for improvement is at least as strong as the original evidence of a problem existing. And it's easy to find out if the bad feelings are reduced or gone by asking. See some examples in the podcast summary here[3] talking about studying the effectiveness of the therapy app they are working on: "two groups, including 60 participants with moderate to extremely severe depression at the start of the day, and 73 participants with no or only mild feelings of depression. [...] The reductions in depression in both groups, as well as the additional six negative feelings, were substantially greater than the reductions reported in large numbers of published outcome studies with cognitive therapy, other schools of therapy, and antidepressants. All seven types of feelings were dramatically reduced in both groups. For example, the depression reduction was 62% and 51% in the severe and mild groups, respectively, and the anger reduction was 70% and 81%, respectively"
and
"The feedback we received on the app has been largely totally unexpected. Some things that we thought were blow-away were criticized, and some parts that we thought were weak were strongly celebrated. This experience has been much like using David’s feedback scales in therapy. Therapists learn that their perceptions of how their patient feel are often not[?] off-base, and that many of your favorite techniques and strategies are not effective. This information, if processed with respect and humility, can transform your clinical practice."
[1] Dr Burns does the Feeling Good podcast ( https://feelinggood.com/list-of-feeling-good-podcasts/ ) and book, is a retired Professor from Stanford Uni, was a pioneer in Cognitive Behavioural Therapy, and now works promoting his TEAMS CBT model which has insights on how to hone in quickly on the reasons people are stuck and can't change, and then how to get past that.
With emotional dysregulation or trauma, which comes in many varieties and is more common than people realize, the path towards healing often involves someone feeling "worse" at first as they begin to face pain and emotions that have been suppressed
Someone who hasn't yet overcome their biggest difficulties won't have deep insight into their various psychological states and frames of mind. Without proper guidance, attempts to measure what's going on and assess progress can cause confusion and frustration. Especially if they aren't receiving helpful treatment, which is unfortunately far too common.
I think there is potential for measurement to help, but it's a difficult thing to do well.
This is all simply an aspect of the more general issue of how psychology and psychiatry are not well-developed areas of practice. Humanity is still learning how to effectively approach these problems.
My dad was a dentist in a small, rural town. He cared a great deal about the quality of his work. He died 17 years ago, and my family still runs into his patients who mention how their new dentists rave about the durability of his work.
So, there are dentists who aren’t in it just for the money. It is anecdotal, but so is the article. For that matter, the bad dentist was caught by a good dentist.
I wonder if there's some correlation between rural dentists and quality of care. On one side you'd have the argument that they're probably in less need of money and so can be more honest, because if they wanted more money/patients they'd move to the cities, on the other, if they're the only business around they can do whatever they'd want.
I strongly suspect it leans toward the former though, as even a small town will have multiple dentists, and many of the rural dental offices are basically hereditary.
I'll preface this by saying that yes there are unethical dentists out there and clearly this Lund guy is one of them and patients should never hesitate to get a second opinion if they feel uncertain.
However, this whole thing would be more informative and impressive if they had gone after the elephant in the room. Aspen Dental overtreats more than the rest of the dentists in USA put together. They are a "large health-care organization with substantial oversight... and standardized treatment regimens", but that oversight and standardization is geared entirely toward convincing every patient to get at least ten crowns. Aspen Dental are also large enough to hire lots of lawyers, so Atlantic isn't going to touch that with a ten-foot pole.
The thread had been up for hours when I commented. I think one must "get in on the ground floor" to get to the top of the page. Thanks for the kind words!
A compelling book on tooth care is Kiss Your Dentist Goodbye by Ellie Phillips.
It advocates for:
- Using flouride toothpaste.
- Using a combo of bad-bacteria-killing mouthwash and flouride mouthwash (especially before bed).
- Eating or finishing meals with tooth-protective foods.
- Chewing xylitol [0] gum or mints. Xylitol is a sugar-replacement (with a lower insulin response) found in plants . I think Epic Dental has the most reasonably priced stuff that I would trust.
Her routine is here [1]. I think her suggestions are reasonable. She has a product line, but you can use generic products that fit her guidelines. Just match up the ingredients.
Also, a couple good points in the book Breath by James Nestor:
- We have malformed mouths and teeth because we don't do enough serious chewing. Think bread/mac and cheese/peanut butter vs carrots/steak/celery.
- Mouth breathing is bad. Your mouth dries out and this assists tooth problems. You can solve this while sleeping by taping your lips together.
If you enter the world of sleep apnea treatments its kind of actually quite common. The alternative sometimes is using head gear apparatus and look like darth vader. I mean even for fighting mouth breathing during sleep its been recommend.
#2 is terrible advice. Acidic food weakens your enamel. Brushing after eating will make things worse. It's actually recommended that you wait after eating acidic foods to brush. Rinsing (with water) is totally safe, though.
Heh I thought you were going for a 2. "there is no step 2" joke, or suggesting that you could just remove all your teeth and then have no tooth problems anymore.
I'd love to see a section of the store or even a whole store dedicated to "no added sugar/sweeteners". It is really hard to find a surprisingly large amounts of food that don't come with sugar or corn syrup.
Daily mouthwash is a horrible idea. Mouthwash contains Corsodyl which has been shown to increase blood pressure. Regularly blasting any part of your body with a harsh antiseptic is probably a bad idea. It took us decades to realize that antibiotics messes up our gut floura, I'm sure we'll see similar consequence for mouth bacteria with mouthwash.
This is wrong. You didn't read the linked resources.
I just checked, and neither of the mouthwashes I use have Corsodyl as active or inactive ingredients.
Also, uh, don't drink your mouthwash, spit it out.
Since everything we do has tradeoffs, I'm okay with using an antiseptic that is spit then rinsed (per the routine) if I'm going to eat ice cream and bread.
An intuitive analogy is your gut is like a rainforest. It's hard for any one species to become overly dominant since it's a very dynamic system with many species that have optimized to even specific tree species. However in extreme environments like the Arctic there are only a handful of species as the environment is unfriendly to all. Antibiotic is akin to burning down a rainforest which does get rid of a few bad species, but also creates all the other species that keep the bad species in check. Post fire if a bad species is the first to take hold the entire area is fucked.
Your mouth has it's own floura. Sure you can blast everything away but eventually you'll be far more securable to some alcohol (or whatever antiseptic) resistant bad bug and you will get very sick for a very long time.
>Also, uh, don't drink your mouthwash, spit it out.
doesn't cut it for me. someone I know who doesn't smoke or drink and was sub-40 years old got diagnosed with tongue cancer. Cancer specialists were miffed at the cause. The only thing that stood out: he was a meticulous user of mouthwash 3x a day since he was a teenager.
Sometimes people just get unlucky and there's not some direct causal factor. Yes, it could have been the mouthwash. It also could have been a combination of their germline genome having some unfortunate mutations and/or a series of unlucky somatic mutations.
If mouthwash has harmful ingredients keeping it in your mouth for a prolonged duration and spitting it out instead of drinking it will not solve your problems, contrary to the quoted line.
If an patient who is an outlier exhibits an extreme habit related to the affected cancerous organ, it seems advisable to take note even if it is possible there are undiscovered more serious contributing factors.
I mean, you are making a jump from correlation to causation. There is a reason science does not use anecdotes and relies on statistics, p values, and, confidence intervals.
That being said, did you happen to know what ingredients were in play, since he was using the same product for ~>20 years it sounds like, maybe the carcinogen landscape was much more under researched that long ago? I mean leaded gas was still sold in the US 'til 96 -- even though theres just so much evidence of it being harmful to the nth degree.
Even more reason not to use alcohol mouthwash, interesting. I did not previously use it just for the fact it dries your mouth and that exacerbates bad breath.
>And why pray tell, should I disregard cancer specialist
Not doing such a thing, your words were directly "someone I know who doesn't smoke or drink and was sub-40 years old got diagnosed with tongue cancer." -- which is different from your words here where you link a study -- and I appreciate you for doing.
Many argue that pushing flouride on the public is an outright scam and lie. Fluoride is a known toxic substance that damages the body and can compromise one's health. It was being dumped in the water by factories, and the industry helped pull off a con by paying for studies to show that their industrial waste was actually "good" for people. The public fell for it, and here we are today. All these people drinking in and brushing with the so-called miracle of flouride, yet so many cavities (and other health problems).
There are multiple studies showing how flouride in toothpaste and drinking water prevents cavities, and is non toxic. Where is your evidence to the contrary?
Flouride is toxic, period. The argument that you are likely trying to make, to oppose my statement, is how much of it can a person ingest before having negative health effects and is it really good for your teeth. It might be better to read about its history of usage, and that many countries do not allow flouride in their drinking water, and have a cavity rate that is equal or less than that of the U.S.
Some communities have a naturally-occurring fluoride level higher than the amount that is added in other communities for tooth health. (As described at your link, these places see some cases of fluorosis, but no one dies of cancer.) That is, only very small non-toxic amounts of fluoride are ever added. These amounts have radically improved the oral health of children in those communities. Poor children, who have little access to dentists in red states, would be especially harmed if cranks have their way and fluoridation ceases.
Let me guess, you also don't want iodine to be added to salt?
After experiencing this first hand in the US it was really nice to return back to Europe where in my opinion unnecessary operations and active selling of special cleaning procedures are somewhat more rare.
I just had my yearly checkup and the dentist again noticed few small inactive cavities and said we should just monitor them like last year.
In Germany pretty much every dentist will recommend you a "profesionelle Zahnreinigung" (professional tooth cleaning), and if you lookup what studies exist to show that it does any good, there's only one study that's basically useless (they tested a combination of the professional tooth cleaning and a lecture on proper self tooth cleaning and showed that this helps, so in the end you know one of those or a combination helps, but you don't know which one). So yeah, this is pretty much a problem in Europe, too.
I drink a lot of coffee and black tea. I very much value the half-yearly cleaning just to remove the dark spots that are not a health-risk, but look bad.
And almost every private tooth health insurance covers those anyway, so if you have that for others reasons, it’s included.
The tooth cleaning is much the same as what happens on the yearly cleaning your insurance pays for (and highly recommends you do). Is that one also "basically useless"? How much study does one need to judge if mechanical dental tartar removal is beneficial?
In my experience we've got these two options here:
- socialized dentistry, where unless you're screaming in pain dentists take two peeks into your mouth and say it's fine and tell you to get out so they can take the next patient in the 200 person line outside (and shill their afternoon private practice to you if they happen to be the more shady type)
- private dentistry, where they'll always find something random that somehow materialized out of thin air since you were there 6 months ago to fix and bill you half your monthly salary for it, despite saying they fixed everything last time
Like, can we please get some fuckin middle ground...
In the UK, loads of people are desperate to get an NHS dentist. When slots become available they are snapped up immediately, often by people that are more than capable of paying privately. I would suggest many would prefer the socialised system, perhaps because the over treatment is less likely to happen.
IIRC, Brazil includes dentistry in its regular healthcare. Cleanings are cheap-to-free so folks wind up getting cleanings and the like. There are also a lot of dentists in Brazil - I think it is the 3rd largest dental system and employes something like 15% of the world's dentists. Hardly rushing folks through while they scream in pain.
(I don't know the intricacies of the Brazilian system other than it includes dentistry and is a combination of private and public systems, so I might be wrong. Folks from Brazil seem to be happy enough with it, but they might be biased).
I'm Brazilian, lived in Portugal, Germany and Australia for a few years each, and can attest that dental care in Brazil is at least 100x better in every way. It's much less bureaucratic.
Many universities offer free-of-charge consultations, although in a limited fashion. In big cities, I've seen mobile clinics helping the homeless. It's just part of the culture now. I'll even risk saying that Brazilians don't smoke because it stains the teeth. Lots of people do drink black coffee but they'll brush their teeth afterwards.
A private company called Sorridents has taken over dentistry in Brazil with more than 500 branches. It works like Subway/McDonald's. It's affordable.
Yes, there are many more dental professionals in Brazil, but the population also spends more on it (relative to income), so it balances out. You can even get dental insurance through your energy company, but I believe the vast majority of the population doesn't have any [1].
As an anecdote, I've waited TWO YEARS for Bupa (Australia) to tell me that my wisdom teeth extraction would cost 7000AUD and they'd need to move an entire team to a hospital to do it, and I'd need to pay for general anesthesia too (some 1500-200AUD more), which is absurd. I've also consulted with three other top-rated dentists in Sydney who told me the same. I flew to Brazil, paid 500AUD in a top-notch clinic, and the procedure took less than an hour.
In both Germany and Australia, dental cleaning felt rushed, polishing wasn't done properly, they always came up a thousand little things that added to the final cost. It's ugly, it's scammy.
In Portugal you can get decent dental care due to the large amount of Brazilian dentists.
>- socialized dentistry, where unless you're screaming in pain dentists take two peeks into your mouth and say it's fine and tell you to get out so they can take the next patient in the 200 person line outside (and shill their afternoon private practice to you if they happen to be the more shady type)
What would you define as socialised healthcare? Like would Belgium or the like qualify?
> ...whose practice was a convenient 10-minute walk from Mitchell’s home,
Not a good criteria for choosing a dentist. My dentist is a 4 hour drive away. I moved 10 years ago and I prefer the inconvenience over the risk that someone else will be selling me treatments I don't need.
What I have learned over the years is that your teeth are in a constant state of deterioration and will never be perfect. There is always some treatment that can be medically justified but, often, it doesn't need to be done.
Sure it is - it is about as good as anything else you might wind up with, especially if you don't know anyone in the area, don't have a dentist for whatever reason, or simply cannot afford to travel such distances.
And to be fair, you won't realistically know that someone is selling you treatments you do not need and you can always decline if you suspect such a thing. I'm guessing the gas money will almost cover a second opinion at a local dentist, honestly.
Full disclosure: I chose my doctor based on proximity. I was fairly new in the country, had no way to get references, and figured it'd be about the same risk as any other method, all of which were mere guesses. Probably the best doctor I've had.
Especially if you get into procedures like crowns you are probably talking multiple visits. Mind you, they don't need to be next door. I kept the dentist I had when I was working 45 minutes away because I like them and it's not that much of an inconvenience to drive up there.
Always be skeptical when the person giving you a diagnosis also directly benefits from giving you a particular diagnosis. This goes for dentists, banking and so much more.
Can you give an example of a professional for whom this isn’t the case? Maybe a general practice doctor referring to a specialist? But often this involves trips back to the GP for checkups as well.
In many cases, you approach the business with the "diagnosis" already worked out: moving companies, car rental, electronic parts, etc. In fact those businesses usually have automated or semi-automated pricing. When the business needs to evaluate you individually, they have at least a temptation to take more money than they should. That temptation is either capped by regulation or reputation in my experience.
Most home inspectors are beholden to real estate agents. While it may seem like you are the client because you are paying them, at the end of the day it's the real estate agent they want to make happy, so they keep sending them business. That may mean not being too thorough, in order to not "kill the deal," or finding some stuff to request repair/credit for to show the buyer how hard the agent is working to earn their commission, but rarely does it mean fully working in the best interests of the buyer.
That's why I qualified with the word certain. I'd never use an inspector recommended by my agent and I'm not sure how to find a trustworthy inspector. In the past I've used a person recommended by somebody I trust.
What you said is true though and it became clear to me during the inspection. At the time my realtor told me my inspector was being ridiculous because he was documenting lots of things that weren't really problems but were recommendations and things to be watched.
I don't even really consider "home inspector finds a fault that cancels the sale" to be a "thing" - I'm mainly hiring them to find all the likely things I'll need to work on going into the house.
And the quality varies incredibly because they're basically paid to rubber stamp things (and usually if they DO find something, it's already been disclosed or is quite obvious).
Some go to more trouble and I'd say that running a camera down the sewer line is a good indicator that they're doing this (and ALWAYS GET THIS DONE if the house hasn't been lived in recently, or just in general).
https://structuretech.com/all-blogs/ is an example of one that uses their blog to promote, and they mention "roof walk" and "sewer camera" as examples of their value-add. They also have an example report to look at (many, many reports end up with fifty pages of photographs and 'an expert should look at this' which is great for covering the inspector's arse but useless for the homeowner).
Inspectors that openly offer inspections for houses that are not being sold would be another one, they have to provide value.
In my state, annual automobile safety inspections are required. I have always been suspicious of this because naturally the auto shop doing the inspection offers to repair any flaws they discover. In most cases, the safety issues are obvious (thin tire treads, worn brakes, rust damage) so if you have a little bit of understanding you can verify the shop's claims and seek repairs elsewhere if the cost is too high.
It looks that way to the consumer, but I don’t believe that to be true. I’ve worked in the industry for a few years and most of insurance products I’ve seen are structured in a way that the company reviewing and processing the claim isn’t actually responsible for paying out the claim.
> I’ve worked in the industry for a few years and most of insurance products I’ve seen are structured in a way that the company reviewing and processing the claim isn’t actually responsible for paying out the claim.
Is this in the US context, or whereever you're from?
I had a dentist in SF that did this, first visit to him I had 12 (?!) cavities that needed filling. Got suspicious -- their office was very very nice and in a prime location -- more importantly, none of my teeth hurt. A second opinion confirmed that the fillings were not necessary at that time. I did start flossing regularly as a result, so that I don't have to rely on dentistry as much.
My dad loves to joke that he chose his dentist because he was the one who found the fewest cavities. As a kid I thought my dad made fun of his dentist, as an adult I realized he made fun of the other ones.
These days I just ignore the dentist when they say I need fillings, unless I am experiencing pain. And nearly all the dental pain I have experienced has been post-op.
I usually start flossing much more diligently a couple of weeks before my dentist visits, so that my teeth have the appearance of being better-maintained. I believe this results in more honesty from the dentist. In other words, my instinct is that they rely on their gut feeling quite a lot for making their "diagnoses." If your teeth look healthy, they are more likely to tell you they are healthy. Don't know WTF they are seeing in those blurry x-rays.
The only reason I go to the dentist at all is for general well-being reasons and polishing. When I don't have insurance, I just skip it.
> These days I just ignore the dentist when they say I need fillings, unless I am experiencing pain.
Careful. It is possible for a cavity to be completely painless up to the point it is so big that the tooth actually completely collapses, and then you get to enjoy something much more annoying than getting a filling (especially a small one) such as a root canal.
If you have small cavities and don't want to get them filled and aren't sure they are the kind that if they grow won't be pain free until it is too late, look into silver diamine fluoride [1].
In the US its official use is to help people with dental hypersensitivity, but it also can stop or greatly slow cavity formation and growth. Dentists in the US can use it off-label for that.
> I usually start flossing much more diligently a couple of weeks before my dentist visits, so that my teeth have the appearance of being better-maintained. I believe this results in more honesty from the dentist. In other words, my instinct is that they rely on their gut feeling quite a lot for making their "diagnoses." If your teeth look healthy, they are more likely to tell you they are healthy. Don't know WTF they are seeing in those blurry x-rays.
I don't know. What you just said 100% resonates with me. But I'm not a dentist. I'm (was) a physicist, and I know the absolute garbage HN constantly writes about physics, so this might just be gellmann effect...
In my experience, the majority of dentists are criminal crooks. It‘s generally not nice to trick and steal from people, but dentists are in the unique position of leaving their victims in severe, chronic pain that can only be fixed by other dentists.
I myself suffer from varying, chronic pain after a pointless visit where two "tiny" holes were drilled.
The problem is you can only evaluate them over years, which is incredibly sucky. I haven't found a solution to working out which dentists are actually the best yet, which makes me loathe to leave the one I have currently because it has been almost 10 years of good care (I can contrast with the bad ones that had fillings that fell out within 3-4 years etc.)
The trust you should afford to a dentist is inversely proportional to the amount of time and energy that dentist promotes teeth whitening products and solutions.
Probably a good heuristic, but weirdly I've never had a dentist try to sell me a single whitening product of any kind. Unfortunately that hasn't prevented some of my dentists from being terrible. Thankfully some of the bad ones have given me such obviously bad advice ('wait until you start feeling pain before you come back to me') that I knew to find another one pronto. I wonder if pushing products differs a lot between countries, my experience is exclusively of Australian dentists, I'd be curious to know if anyone has experience in multiple countries!
Finding a truly good one is astrology. I generally assume that only greedy humans become dentists. And dentistry has infinite possibilities to apply greed to make more money by needles or harmful medical interventions.
All dentists I've tried, found by various methods (including recommedation from a GP I trust) have been dishonest and/or incompetent. A small business, serving laypersons who cannot evaluate the work, is prone to it.
I think the only way is to stick with one dentists, so they see you as a long-term investment.
funfact: Yelp was inspired by the difficulty of finding good dentists.
Now I'm interested in DIY dentistry. Any pointers?
My current dentist of the many years is perfect. She is obsessed with the quality of work and materials, and aims to optimize for being on top of problems vs being conservative in treatment.
Inevitably she will retire... Then I need to find another dentist who cares most about dentistry.
The industry is apparently now dense with dentists obsessed with the business of dentistry, or even “dentist lifestyle influencers” who glamorize the business of dentistry to sell products/courses/whatever to other dentists.
> aims to optimize for being on top of problems vs being conservative in treatment
You should really read the article as this is the exact problem they’re pointing out…that the whole field is rife with treatments that are not evidence-based and that what little evidence has been collected is pointing to significant over-treatment in the field.
The dentist discussed in the article would likely have been described by his patients exactly the way you describe yours. But, according to the article, he ended up settling his civil cases for close to $4m and is facing criminal charges. Which isn’t to say that your dentist is the same, but just that it’s such a natural trust relationship with your dentist that it’s really easy to end up getting procedures that aren’t necessary and dentistry doesn’t even have the data gathering infrastructure to determine which procedures really are necessary. That’s a really dangerous thing when a dentist’s financial interests are aligned with doing more procedures.
Long form journalism tends to frame articles around individual narratives.
However, the article does have this:
Studies that explicitly focus on overtreatment in dentistry are rare, but a recent field experiment provides some clues about its pervasiveness. A team of researchers at ETH Zurich, a Swiss university, asked a volunteer patient with three tiny, shallow cavities to visit 180 randomly selected dentists in Zurich. The Swiss Dental Guidelines state that such minor cavities do not require fillings; rather, the dentist should monitor the decay and encourage the patient to brush regularly, which can reverse the damage. Despite this, 50 of the 180 dentists suggested unnecessary treatment. Their recommendations were incongruous: Collectively, the overzealous dentists singled out 13 different teeth for drilling; each advised one to six fillings. Similarly, in an investigation for Reader’s Digest, the writer William Ecenbarger visited 50 dentists in 28 states in the U.S. and received prescriptions ranging from a single crown to a full-mouth reconstruction, with the price tag starting at about $500 and going up to nearly $30,000.
Are the dental guidelines any good though in the sense of people actually brushing their teeth and eating properly so as to reverse the damage? Dentists are one of the few professions I've found that will happily chastise their customers, and often rightly so, for failing to adhere to proper dental maintenance. In that case I could understand just going ahead with a filling even if technically and ideally the decay could be reversed, simply because most people probably won't do what's necessary.
That trade thing is how I have realized I feel about dentistry.
I've always felt it was a little bit science and a little bit art. I don't think there's an exact set of steps to every tooth and it's problem. There's just too many variables, so they have to figure it out as they go.
Two dentists in the same clinic might not do it the same way. Problem wise, two identical repairs might wear differently, causing one to last a lifetime, but another to fall out in a couple of years. A mouth gets a lot of use.
I am, however, lucky enough that my dentist will see two paths, and offer the less expensive option with a "wait and see" disclaimer. I've had no problems with those repairs, where I'm positive some others would have immediately escalated from the filling to a root canal, filling, crown, etc path.
If only there was as much development (pun intended) in dentistry as there is in software engineering. With all the amazing advances in medicine we're experiencing it often feels to me like dentistry is stuck.
Also get a second professional opinion when the recommended procedure seems too invasive just to "save you costs". Some things do need a more expensive procedure now (e.g. a crown) to save you from much higher costs later (e.g. a dental implant).
And do confront your doctors with one another's opinion. A well meaning doctor can surely stand by their treatment recommendations with arguments and counter-arguments.
What I can't understand is how dental managed to escape medical coverage, not just in the US but seemingly globally. Just this year the main confederation of Swedish labor unions will be pushing for consolidation of dental into medical but... how did we even get here, especially considering how fragmented the dental industry seems to be (mostly comprised of small private practices with some public ones to supplement.) It's doesn't exactly seem like the industry most ripe for a cartel or conspiracy, yet here we are...
If it were part of medical, I'd expect to see most expensive procedures (that aren't already covered under medical) such as crowns, implants, and root canals wouldn't be covered because they'd be considered cosmetic given that extraction is usually an option. Routine dentistry is pretty inexpensive, especially in the context of medical costs generally.
Any company dental plan I've ever had is mostly a tax advantaged benefit that saves you a bit of money but the annual max of mine is something like $2,000.
That would be completely covered where I am... Anything that could create social or mental health issues like that would be. Maybe you should argue for better insurance than worse...
I had an experience as a child where I _suspect_ my parents and I may have been taken advantage of by a dentist, and this article makes me think that it's not such an improbable thought. Every single time my parents took me for a 6-monthly cleaning, the dentist found new cavities. I'd have to get at least one new filling after each cleaning, sometimes two. We were told this was pretty common because I had braces and wasn't as diligent as I should have been with flossing. My needle phobia was especially bad at the time and every visit was like a nightmare.
When my last cleaning came around, they of course found another cavity. When I was taken in to get it filled, I panicked in fear of the needle and threw up in the chair. They told my mom we'd have to do the procedure on another day. The dental practice did not know that we were about to move to another country, and wouldn't have time to come back. My mom decided to just wait until after the move.
When I was taken to the dentist after moving about the tooth that was meant to be filled, they had no idea what we were talking about. They didn't see anything on the x-rays and said my teeth were fine.
Ever since then I wondered how many of those filling I even needed.
I'd avoided dentists ever since and didn't see one almost 15 years until a couple of years ago when I had a wisdom tooth that needed to be taken out. I was worried that when they'd take a look at my teeth they'd find all sorts of things wrong after all that time. But aside from the wisdom tooth and a tiny cavity that they said could heal on its own, they said my teeth were fine and I didn't need to do anything else except for being better about flossing (which is when I finally got really diligent about it).
(And for the wisdom tooth extraction I specifically found a clinic that specialized in dental phobia. They let me opt for a "Wand" device to do the anesthesia of the tooth instead of a traditional needle. It looks much less like a needle, and the release of the anesthetic is entirely controlled by the device itself and not by the hand of the dentist [though of course the dentist is still the one configuring it]. That somehow made me feel better about the whole thing, since I knew the device would release anesthetic at a stable and "ideal" rate. I trusted it more than a human.)
When I owned a bar for a short period of time a regular was a dentist and he said most dental procedures are unnecessary. I mentioned the last time i went to the dentist 10 years ago I was told I had seven cavities. He took a quick look and called their bullshit.
What I didn't hear often enough when listening about teeth health is how important is diet and lifestyle for the teeh health. While there was talk about brushing and regular dentist visits, the diet factor was mentioned briefly and half-heartedly that you shouldn't eat sugar. Which nobody listened to anyway (especially as a kid).
How much more is there to it is well explained in Weston A. Price - Nutrition and Physical Degeneration: A Comparison of Primitive and Modern Diets and Their Effects [0]
Just be wary of the foundation, they are quacky often. Just read the book.
Weston Price (Dentist) travelled the world looking at indigenous people eating their traditional diet, and found they had very little tooth decay. Tooth decay starts up with the modern refined flour, refined sugar, diets. As well he found that they have very round wide mouths and not much teeth overcrowding that is so common today, and wide noses and nostrils, easy breathing through the nose. He put it down to nutrients in food, things like eating organ meats, around the time of Upton Sinclair, re-disovery of Vitamin C for scurvy and so on. e.g. https://elliottwall.com/wp-content/uploads/2011/11/westonpri...
More modern day dentist Dr John Mew suggests that wide, round dental arches with plenty of room for teeth comes from a lot of hard chewing; the tongue pressing up against the roof of the mouth to mash food also exerts an outward pressure which shapes children's mouths / faces to be wider, and that's missing with modern diets.
People elsewhere in this thread have brought up mouth breathing as a thing which dries the saliva and worsens tooth decay, that's affected by having narrow nostrils which are more difficult to breathe through, which could be affected by childhood nutrition and chewing?
Fee for service in health care is not compatible with prevention. The vast majority of oral issues are preventable because they stem from bacterial infections. Dentists take full advantage of information asymmetry: patients assume the dentist knows best. They are incentivized to maintain the status quo that has patients pay enormous costs out of pocket for procedures that could have been prevented early on.
At Bristle, we’ve created an at-home oral health test that also pairs you with ingredient recommendations to prevent the progression of oral disease. The goal is to give data around oral health without the misaligned incentives of a practitioner who benefits from your demise.
I had to switch dentists last year due to my former, excellent dentist closing his practice. I had heard of these kinds of stories. I knew I had a cracked filling (my old dentist had told me so) and his advice on a previous visit was "you should get it fixed some time, but it's not urgent." When my new dentist also identified the cracked filling and said exactly the same thing, I figured he was not out to rip me off, or else he would have said it was an urgent problem requiring a filling or even root canal therapy.
I live in Silicon Valley. I went to one of the few clinics covered by my insurance, and the dentist spoke in heavily accented English I could barely understand, exacerbated by wearing a mask and a face guard. They showed me my X-rays and told me “something something cavity something something” and had me make an appointment for a filling. I came back and got the filling, then they told me to make another appointment for another filling. This happened eleven times. Eleven fillings after not having received one filling in the previous 20 years.
For my next checkup, I searched and searched for a dentist who spoke in unaccented English I could clearly understand. He checked my teeth and cheerfully told me I needed to have all my lower front teeth removed and a bridge implant. Out of pocket cost: $30,000.
I couldn’t possibly afford this and decided to get a second opinion. The problem is, my insurance only covers one checkup every 6 months. In the meantime I agonized over how I would possibly pay for my extensive dental work, and I managed to find another dentist with whom I could communicate.
I asked this dentist if I needed the $30,000 procedure and she scoffed!
I was instantly furious and gave the Rolls Royce doctor bad reviews on Yelp and Google Maps. I’ve been getting a real-life lesson on the practices described in the article. I plan on sharing it with everyone I know.
My father is a periodontist turned attorney. AFAIK, he actually started the specialty of dental malpractice. I grew up seeing a lot of destroyed mouths and people suffering.
I’ve learned from him that over treatment and bad quality work is shockingly common. Part of the reason is how dentistry is taught in this country: people take out very expensive loans for dental school, so they want to start practicing right away while also over-treating to pay down loans. It used to be cheaper and people would apprentice — that is now rare. You see this in medicine too where they pack as many people as possible into a day, who cares if the quality is low per person.
The vast majority of dentists he sues are general dentists. They often don’t have the training and/or equipment to do surgery, and it results in things like drilling into nerves which cannot be undone. A lifetime of burning pain is the consequence. Again: no undo.
My best advice is to always see a specialist, even for a teeth cleaning. They have additional schooling and demonstrate a desire to go deeper in the profession. Prosthodontists will do cleanings, and their inspection will be far more valuable than a general/family dentist. They’ll also know which specialists to send you to for various procedures and won’t attempt to do something outside of their training.
I have been fortunate to have had an excellent dentist in Japan.
About a year ago, I was told by a dentist (in a larger clinic) I needed to have gold filling in my molars (because gold is least reactive, better than ceramic and gets the dentist a pretty penny). I was quoted ~$500 after the insurance. Also suggested was some SMILE UV procedure to whiten the enamel. I was reluctant as well as mortified. The whole convincing act sounded more like a sales pitch. I went to a second dentist, who runs his own singularly run establishment (the current one in question) and he flatly told me 'no'. My teeth were in good shape mostly (minus some coffee stains & a cavity). Since it was about closing time, he sat me down over a quick bite & went through the dental physiology - and why he considered it pointless. In the end, he added since I was on insurance I had nothing much to lose monetarily, but by doing Dentist A's suggestions, I was primed to keep visiting every few years for fixes. He had nothing to gain by turning me away. That was a huge confidence booster. Honesty was a huge factor in getting my trust.
It opened my eyes to the fact that the vaunted & strictly regulated Japanese health care has its share of bad apples too. Dental treatment is a money spinner even in Japan. Although, mostly operating assiduously and in good faith, we need to still look out for some bad actors. (I have another terrible story - but it pertains to opthalmologists)
Bonus: Since he turned out such a nice guy I get him souvenir candies (ironic!) from wherever I go traveling. And he cauterizes my sporadic canker mouth sores without ever charging a dime :)
> In other medical contexts, such as a visit to a general practitioner or a cardiologist, we are fairly accustomed to seeking a second opinion before agreeing to surgery or an expensive regimen of pills with harsh side effects. But in the dentist’s office—perhaps because we both dread dental procedures and belittle their medical significance—the impulse is to comply without much consideration, to get the whole thing over with as quickly as possible.
Around 10 years ago, during one of the dentists appointment, my wife had to perform an x-ray scan of the whole mouth. Besides the stuff dentist wanted to confirm, he found out that she has her wisdom teeth grew in a little problematic direction that might become painful in very short time and suggested to remove them before that happens.
That said, such operation would require narcosis. Both of us are very skeptical when someone wants to do something for us that requires putting us into that state so we've gone to another dentist to get another opinion.
Turned out, that other dentist said that he don't see any problem with my wife's wisdom teeth and warned us, that the operation other dentist suggested was very dangerous and had high probability that it could break some jaw nerves very easily which could lead to partly face paralysis.
So yeah, 10 years has passed and my wife has never experienced any pain caused by her wisdom teeth - maybe got lucky or maybe that 1st dentist was just plain wrong.
But in the end I've always tend to be warned and while having any doubts, it's worth to spend some money just to double check if suggested treatment is really good for us (or necessary).
After college, I went to a new dentist on the recommendation of a coworker, a father-son practice. It was fine for a few years, then all of a sudden, multiple cavities. They mentioned a failed sealant which I halfway buy, but they "found" a few others.
I'd never had a filling before, so this was a very big deal for me. The dentist had time, so he just did it right after my cleaning. The only word I have for how I felt was raped. I don't use that lightly. It was emotionally traumatic to have someone pressure you like that, not give you a clear choice, and violate your body.
I kept going there just because I was lazy, and I went on a day the dentist was out of the office, so the hygienist just showed him the xrays. When he found another one several years later, I got a second opinion. He said it was something a more aggressive dentist might go after, so the diagnosis wasn't outright wrong, but probably overly aggressive.
Never went back to the first dentist. 7 years later, it's still fine. I suspect most of my fillings were the same story.
My current dentist probably overtreats with 4 cleanings per year, but I'd rather pay for the extra cleanings.
This article rings true for me. As an 11 year old I got a root canal. Now that I am an adult / parent I realize how evil that dentist really was. I still have that fake tooth. My parents could only pay cash - we couldn't afford insurance. So I was a pretty regular patient no matter how advanced my brushing and flossing was. Other kids in my neighborhood had it worse with silver front teeth.
Part of the problem is that dentists don't have the incentive nor arguably the training and knowledge to cure the problem. Cavities and lost teeth, brings them money. So don't expect them to be looking around for cures like regrowing teeth or reversing cavities, unless some unusual "one in a several billion" fellow comes along (who the others won't like) to change things (like how we got Penicillin or the cure for Polio). A lot of dentists would rather your teeth rot, so you need to pay them, or you make continual monthly payments to them.
The biggest innovation in the last 50 years are titanium dental implants (very expensive) and the use of ceramic and acrylic (more expensive) over the insane amalgam fillings with mercury. And yet, many dentists still put the health hazard of amalgam with mercury in people's mouths (like it's a tradition) or do root canals which keep dead toxic teeth in mouths too. If you want less toxic options, then you must pay for much more expensive procedures.
> over the insane amalgam fillings with mercury. And yet, many dentists still put the health hazard of oamalgam with mercury in people's mouths
The "mercury" metal fillings last much longer - no longer why dentists try to use the fear of mercury poisoning to sell you on a replacement plan. Thanks, but no thanks.
The dose we are exposed to, as patients, is negligible. If there's a health problem, it's for dentists.
This was a helpful article! So far I’ve been lucky to escape what seems to be unfortunately common. One time I saw a dentist who smacked of profits over patients, and he had recommended a deep cleaning. I did it. It sucked. Now I know to get a second opinion!
One great hack I've used to find a good dentist is to find one that used to serve in the armed forces; I reason that they were well trained not to overdiagnose since materials were limited and the military didn't have an unlimited budget, nor did they get paid any more. Thus far, that has been true, and I have liked every dentist I've found that way.
I developed this theory after finding one the 'old fashioned' way, through reviews and word of mouth, and he convinced me I had six cavities and I let him drill and fill two of them before I got a second opinion. Turns out I had no cavities, and didn't need the first two filled either; just a few spots to watch.
My pet peeve is about the number of x-ray my dentist performs. Every time, everything is fine. Feels like the sole reason, is that my insurance pays for me to be radiated once a year.
Like many others I thought my family was predisposed to bad teeth based on the number of diagnosed cavities my sister and I had in HS/college (she had probably 10 fillings before college and I had 3). Then I moved to a new city and that last cavity I’d needed to get treated ASAP suddenly disappeared when I received my new dentist’s check up. She mentioned that there’s a lot of leeway in how cavities are defined and some dentists will lean very aggressive in their diagnosis (IMO crossing over into outright fraud or deception in my case). I’ve never had a cavity since that first dentist.
Anytime the person recommending X is also the person who sells you X, you should be suspicious. The guy who comes to your door saying your roof needs fixing? That guy.
Without discounting any of the bad experiences people have had here: I've been going to the same dentist for 30 years. He never suggested teeth whitening to me, even though I obviously could have benefitted from it, and did when I explicitly asked for it.
In a way, painless dentistry probably increases the profit-seeking. At one time, drilling and other procedures were incredibly painful. Now they're only painful to your wallet.
The current title on The Atlantic is "Is Dentistry a Science?" which IMO is more descriptive and less clickbait-y than "The Truth about Dentistry". @dang : I suggest changing the title.
I changed dentists because I wasnt happy with my old one. He pulled out two tooth because he was not able properly clean the root canals, resulting in a tooth bridge that needed 2 tooths to be sanded down to handle that bridge. The new dentist office told me I had cavities under the super old and also new fillings. They fixed it all and couple months later my tooth aches from cold water and food went away. The unnoticed cavities only found on roentgen were causing me so much problems until the teeth were fixed and healed...
The gratuitous nature of it doesn't bother me as much as the issue that dentistry doesn't seem to have arrived at the 21st century yet.
If you break a finger, the orthopedist doesn't usually give you a finger canal that removes all of the nerves, blood vessels, and bone marrow and replaces it with some kind of resin composite.
Though I guess they are into expensive and horribly invasive hip and knee replacements.
It seems that minimally invasive dentistry is a thing - hopefully it will catch on.
I'm lucky in that we have a good friend who's a dental surgeon, so we're confident in getting good treatment.
But someone is setting up a practice in my area (South London) that fits with what a lot of people here are seeing: he's opened three surgeries in the immediate area, there's lots of advertising for expensive procedures, and he drives a Lamborghini. All that has got to be paid for somehow.
While I am sure these kinds of abuses happen everywhere, I can't help feeling that a lot of them are exacerbated by the US model of healthcare.
In my home country of Romania I sometimes almost have to ask my dentist to take my money. Since on check-ups I usually don't need any work done, he just lets me off without payment. This has actually happened to me a number of different times with different doctors.
Great advice here on dentist selection. But there’s also a takeaway if you ever want to buy a business. It’s way easier to find issues before you buy than after.
I don’t think this acquiring dentist asked some basic questions before buying.
“How much was your revenue last year?”
“$900k”
“How many patients did you see last year?”
“1000”
“ok that’s $900 avg per patient. You charge $50 per cleaning, twice a year…holy shit”
In Italy until not long ago, dentists were a branch of medicine: you had you study medicine and then specialize in dentistry.
Now, also in Italy the Anglo American idea that dentists are not fully medicine has been adopted as well, and at the university there is a path for dentistry alone. And it doesn't make any sense.
One time I had a dentist who told me my tooth hurt because sometimes they just do, but that there wasn't anything clearly wrong and nothing to do about it. He was right (pain subsided with no recurrence) and now I appreciate Dr. G a lot more than I did at the time :)
I was able to find a good dentist by checking whether they offer CEREC. Of course, this is only anecdotal. But it worked for me a handful of times. I'd like to think, if a dentist is offering specialized services, that may serve as a proxy for their competency.
I went to a new dentist over a decade ago, and he wanted to cap 4 of my teeth, because he said they were stained, and he said it probably meant there was a cavity underneath. I changed dentists immediately. I’ve still never had a cavity.
I haven't been to the dentist since 5+ years, and I also don't use toothpaste, just an old toothbrush, floss, and (clove or other) essential oils and massasing my gum when it hurts, few times a year
I had a cavity about 20 years back and the tooth needed to be extracted to alleviate the pain. The dentist said something like “you need to replace that tooth or else your jaw will lose the bone and all your other teeth will shift and it’ll cause problems down the road!” I thought about it and deferred the decision… for 20 years. Recently, I received an X-ray to see how much my teeth shifted and if it was problematic. None.
The total cost to get a new tooth was like $5k. I got an implant done so that a crown could be placed later down the road and I am deferring the crown. And of course, the new dentist is using a similar scare tactic:”act now! The implant might blah blah blah.”
Sometimes, I wonder if dentistry is the world most accepted sham.
How to find a trusty dentist? In my country most seem charlatans doing expensive unneeded procedures or doing a poor job deliberately in order to take more money after a while.
(2019). Posting this material undermining the trustworthiness of medical professionals in the public eye is inexcusable given that we are still in the middle of a pandemic, which continues only because of existing disinformation. It's really disgusting this is allowed on HN let alone reaches the front page.
Disclaimer: Dentist here (and programming enthusiast)
The other side of the story, that nobody really talks about, is the psychological abuse that -dentists- are subjected to, by patients.
As an introduction: I was above average at my uni in terms of clinical and theoretical skills, bought my own practice from a retiring dentist and always behaved 100% ethically (I'm one of those that don't overtreat at all and I built a reputation and a client base that allows me to have more than enough work without resorting to that).
You should know that our days are basically spent in an almost PTSD status after having undergone years of abuse by patients in the form of dark, frustrating patterns that repeat every week. These are behavioral patterns that typically leave us in a frustrating and infuriating lose-lose situation through no fault of our own, and they seem ingrained in the general population.
A few examples: in my clinic and those of my colleagues about 75% of african immigrants that book an appointment, and confirm it 2 days before, end up no-showing for the appointment, and don't even answer the phone when we call them. this happens several times a week. I haven't found a solution because I can't just say "you're an immigrant and I won't book your appointment", nor can I make them prepay while holding native residents exempt from this rule. No-showing means I lose a sizable amount of revenue while having to pay the staff for nothing.
Example 2: a good percentage (20%?) of those with an infection are given antibiotics, I explain they should come back when the pain has subsided, -usually a few days- to perform the root canal / extraction (which will allow me to use anesthesia effectively - it doesnt work when you have an infection) and they also end up no-showing because "it doesnt hurt any more", without bothering to answer their phone when we call them. They call back 2 months later, in pain, demanding to be seen -today-, at which point my blood is boiling. Bear in mind I explain this at least 3 times during the first appointment.
Example 3: randomly, a good patient will turn rogue and decide that the crown I'm doing on her canine "looks too big" or "is too rounded" or some other subjective aesthetic bullshit like that. it's typically a middle-class 50-60 woman. This happened today to me, I showed the crown's thickness to the patient with a measurement tool, it was 0.5 -millimeters- and explained it's physically impossible to make it any thinner. Her answer "it's your problem, I'm not a dentist". These patients will typically then refuse to pay for about 1000$ of work, despite the work being first class, because "they are not happy". This happens randomly and is not predictable despite my best efforts, and is peppered with ridiculous episodes like crying in the chair, calling their husband who will typically back their claims and then start guilt-shaming you with gems like "my wife is so distressed by this. we are both deeply hurt."
Example 4: a patient will randomly decide he will try to leave a bill unpaid, and they will adopt every kind of trick and dark pattern in the playbook. Lies, asking to delay the payment so they can stiff me out of 4 fillings instead of just one etc..this happens multiple times a year.
Example 5: patients taking impressions for, say, a night guard, after being explained the cost and days it takes to make it. We typically deliver then a week later. They will then call a day before their delivery, when the night guard has already been made, saying "doctor I've decided I don't want it any more, I want to cancel the appointment, k thx bye". That is the average message, and I stress the "k thx bye" part where they make it clear they don't even want a reply and it's all said and done (typically because they think they can buy a 20$ nightguard on amazon instead). They will refuse to pay for the nightguard that's already been made and the laboratory has already billed me.
I could go on for hours and cite about 40-50 of these patterns that we see day in and day out, they put you in a very frustrating position where choice 1 is bad and choice 2 is even worse (say, suing the patient for collections as option 1 and taking a direct loss as option 2).
It almost got me burned out and I know several colleagues who either have burned out, or completely changed profession because of the widespread lack of basic respect and fairness from patients.
This happens while, as someone else said, you're in xxx,xxx$ debt, so you can imagine being told unfairly that you have to eat a 1000$ loss for something that's not your fault, tends to make you want to scream. I know I went home shouting in my car more than once asking what I did wrong to be subjected to this bullshit day in and day out.
It's a incredibly abusive profession and it has a very high suicide rate (at like 3x the average for other professions, this is true for most medical professions by the way).
And I won't even talk about the physical toll it has on you because I don't mind working 8 hours even in uncomfortable positions, but seeing the way people lie, cheat and try to blame-shame you tends to take away all faith in humanity.
So yes, there are bad dentists just as there are bad -anything-, but there are also bad patients.
I guess I just wanted to vent and let you see the other side of the coin...we say "no good deed goes unpunished" and it's true indeed
This might be a naïve idea and you didn't ask for any advice, but have you considered doing free/reduced cost work for children or the impoverished? I'm sure you'd face a similar range of responses, but that last line - "no good deed" - made me wonder if using your considerable skills for a bit of charity work might help with the burnout.
Side note: I've had to prepay for appliances and night guards in the past when the cost exceeded some threshold - the latter wound up being supremely disappointing considering it was ~$600 and broke within a fortnight, but I didn't bother complaining to the dentist since the staff would just have to argue with the fab.
>So yes, there are bad dentists just as there are bad -anything-, but there are also bad patients. I guess I just wanted to vent and let you see the other side of the coin...we say "no good deed goes unpunished" and it's true indeed
I hear you, the vast majority of humans are fucked up. On an average the patient is more messed up than the medical practitioner, what to do?
IANAD, but I work at a dental clinic, so I certainly empathize with your complaints. If you don't mind a few suggestions?
If you have a certain profile of patient who often break their appointments, you can simply double-book a certain percentage of them. That is, if you need to schedule three such patients, have two come at 1 PM and the third come at 2 PM. If you expect that one will break, you'll still take care of the other two in two hours. (adjust these times if you are faster or slower) If neither of the 1 PM patients break, or especially if none of them break, somebody will have to wait for a bit. So what? You're a dentist; your time is more valuable than your patients'. If one of these patients gets pissed about this, that's two strikes against her since she is already more likely to break appointments. You don't need a patient with two strikes.
Patients who don't have insurance or who have insufficient insurance (granted, this latter situation is sometimes hard to know in advance) have to pay when they receive service. If you explain this before the work is done (since you have informative treatment plans, patients are never surprised by a bill), then someone who doesn't pay can be referred to the prosecutor for fraud.
Never run "payment plans" through your office. Always use an outside agency like CareCredit or Lending Club. If they won't loan the patient money, then you certainly shouldn't. You do have to pay these firms, so if your schedule is full then nobody gets credit. If your schedule isn't full these fees come out of the marketing budget. If you try to handle loans yourself you'll end up paying more.
Procedures that require lab work are billed on the first appointment, and the patient has to pay half in order for the case to be sent to the lab. You explain this ahead of time, and if you're using the right labs (hint: most of them are in China) you'll still make a profit if someone breaks the second appointment.
The effective dentists I've seen have set up policies that automatically handle bad patient behavior without need for argument or personal involvement. These policies can change based on your experience. You shouldn't be on the front line of implementation, however. The people you have on the phone have to be able to schedule defensively, so you won't be sitting around with no patients. The person you have handling treatment plans has to properly communicate payment terms before you begin expensive procedures. You might have to get involved with particularly evil patients, but if you don't have to address these problems for most patients you'll probably avoid some frustration. Good luck!
Thanks for taking the time to write the suggestions! I work in Europe so the situation is somewhat different here as insurance is used by a very small percentage of patients compared to the US, and I'd say 99% of other offices do not make patients pre-pay, so some of those policies, while probably very good in the US, do not fit our situation very well (the double-booking one I will probably try, though..I've always refrained from it in order to not make patients wait but I guess a little flexibility on both sides is OK).
I work in Europe so the situation is somewhat different here as insurance is used by a very small percentage of patients compared to the US...
I'm jealous of this. Most of our problems come from dealing with insurance.
...99% of other offices do not make patients pre-pay...
This is interesting. By "pre-pay", you mean "pay on the same day that work is done"? Expecting payment afterward seems destined to lead to an untenable collections situation, especially with poorer patients.
Usually patients pay on delivery, so for treatments like a filling it would be the same day that work is done. For lab work such as a mouth guard, they don't pay when we take impressions but rather when the work is delivered
Yeah, that's a tough one. Actually many insurance plans (and Medicaid) say they only accept claims for multi-visit procedures after they're totally done, and we generally follow that rule for insurance. With private-pay patients, however, we've always said pay half at the first visit and half at the last visit (so there's no payment at e.g. a wax try-in). Some patients complain, but I just smile and explain that I can't change the rule.
I was a bit reluctant to read this article, but I am glad I did. But my anxiety did go through the roof while reading it.
Fair warning, this is a long post with a lot of buildup of my own experience with the dentist. The relevant part is the last couple paragraphs but context is all before.
A few years ago I had horrible dental anxiety. Enough so that I would have a fight or flight moment just sitting in a chair. When I was young (baby teeth coming out age) I had been told that I was going in specifically so some teeth could be loosened so they would come out naturally. That did not happen, they pulled them outright and that forever broke my trust. They even had to use those sizer like clamps to keep my mouth open (the ones that sit on your tongue, not the nice cheek ones we have now) I was lied too, and at a young age. Maybe they though I would be less scared but it hurt my trust going forward. But basically I did not go to the dentist after that point unless my parents dragged me... and I put up enough of a fight both getting there and in the chair that they gave up. I wasn't a brat, I had no issue with the doctor... I was just scared out of my god damn mind. Once I became an adult I didn't go to the dentist for... 6 or so years.
I even chipped a tooth and the idea of going the dentist scared me so much that I was desperately looking for some "secret" solution to grow back the tooth... as an adult. But I even ignored that.
Finally my wisdom teeth happened. And they hurt like hell, but they actually came in fine. But they got a cavity because while the teeth themselves came in, fitting brush between them is another story. I was in horrible pain and I could not let it go any longer. I was still scared shitless but... pain is quite the motivator.
I remember the first Dentist I went to. It was a big chain (I don't know if national but there are a lot of them. I called them and explained my situation. I stressed that I had a lot of dental anxiety and why. They reassured me that they had someone who specialized in this. So I get there... explain again why I have anxiety. He proceeds to do the examination without tools, just taking a look at things. He does the X-rays. And then right as we are about to leave, he takes one of the tools and quickly scrapes one of my teeth (with no warning)... I have not wanted to run out of a place quicker in my life. It wasn't a necessary scrape, I am convinced he did it to be like "See this isn't too bad" He completely ignored WHY I had anxiety. I was not happy... It isn't the tools it was the being lied too. The tools never bothered me (that's partially a lie, if I had to see the open mouth clamps that they used when I was young I would probably scream).
Finally I found another dentist. Slightly more upscale to be honest, but there were some basic things they did that tremendously helped me... like before I ever came in the dentist called me to chat to see how I was handling the pain, to make sure I was comfortable with what the appointment (to be clear this was not his assistant, but the actual dentist). I got to meet him on my terms, home on my couch. When I finally got there I never felt rushed, I was told I could come in early and just sit in the chair if I needed (not sit back until I was ready). I was checked on by various people during this time, but when he finally came in for the actual appointment I was laying back in the chair... anxious but calm because I got there on my terms.
Flash forward... and I have for sure had a fair number of operations from them. 3 teeth extractions (2 of them being impacted with each other), 2 of my wisdom teeth came out, 2 root canals, several crowns and I don't know how many cavities at this point. I also had to have a deep cleaning and now I go in for a cleaning every 3 months to manage that. There is that voice in the back of my mind that wonders if it was all necessary. If I actually need to go in every 3 months. But I find myself reluctant to think about that because I know that... if it wasn't for them I would not be working on my teeth at all. I strongly feel like if I tried to go somewhere else, my anxiety would not be as bad but a lot of my comfort now is tied to my relationship with them.
I know horror stories like what is outlined in this article are nothing new and we have heard things like this before... but I wish this particular industry was better.
I'm not a dentist but run an oral health/microbiome testing company, so I've been "in the industry" for some time as a non-incumbent and I've had the opportunity to connect with almost every stakeholder (patients, providers/dentists, hygienists, and payers) in dental care. My background is in genomics/sequencing so most of my experience pre-company was on the systemic health/medical side.
A lot of the problems are the result of misaligned incentives. While it's applicable to almost all of healthcare, it's especially prevalent in dental. Providing high-level what I've seen with the understanding that I am talking about the worst outcomes of our care model and certainly not hitting all of the problems. That said, I have met many more dentists who genuinely care about their patients than those who don't - and I truly believe that is the norm.
*Payers*
Dental insurance is glorified discounting. Medical insurance provides annual out-of-pocket maximums (deductibles) where anything you pay beyond that is covered by the insurer. Dental insurance is the opposite. There is an annual maximum the insurer will cover (usually ~$1500) and anything beyond that is covered by the patient. In both cases there are some covered services (medical: checkups, some tests, etc. dental: X-rays, cleanings, etc.) but the second you have something even marginally serious your insurance SHOULD kick in. The problem with dental is that it doesn't. I've spoken with people that had to defer necessary procedures for a year because insurance could only cover half - so 1/2 this year and 1/2 next year.
The problem with this model is that while medical insurance is (theoretically) more incentivized to keep costs low since they will have to pay for major care, dental insurance has a natural ceiling. Yes, if you need $5k of dental work the insurer "suffers" - but it's maxed out for whatever your coverage limit is. There's not a severe financial downside to extensive care.
*Providers*
Complimentary to the model of dental insurance is a fee-for-service (FFS) model for care. What this means is that providers are paid based on services. In other words, a provider makes more money doing a cavity filling than not having to do one because they kept you healthy.
The extreme opposite would be a model where a dentist was financially penalized every time you needed a filling - you can imagine how the relationship and role of the provider would change.
Something that gets overlooked, but is important to call out, is that the system for becoming a dentist doesn't help. There are 4 years of dental school. When you graduate, you're likely $XXX,XXX in debt. On top of that, private practice is still extremely prevalent in dental care - so add another $XXX,XXX in debt. Plus the cost of the equipment you need. This isn't an excuse, but its a reality for many dentists. When you combine massive debt and a care model that prioritizes paying for procedures the result is what we see today.
The other problem is that this misalignment means providers have to make personal/ethical choices around care. Sometimes those choices mean performing unnecessary procedures on patients. Sometimes it's the opposite, and the provider takes a personal hit on revenue. So you end up with 5 second-opinions, none of which line up to the others. A provider should not have to choose - or eve consider - ethical responsibility to patients vs. financial stability.
*Patients*
We - patients - get shafted in dental care. Our system is incentivized to reactively treat disease over maintaining good health. On average we pay [40% of dental expenditures out of pocket](https://www.carequest.org/system/files/CareQuest-Institute-B...). That's ~4x more than the average for all other healthcare services.
We're left to navigate oral care on our own. Of course you're skeptical when a dentist says you need 10 fillings - they're incentivized to perform the procedures. Would you be as skeptical if you knew the dentist was getting charged $50 for every filling they had to do? Do you think the care model would change if dental insurers suddenly had to pay for your $10k dental procedure instead of you?
Cavities and gum disease - largely preventable conditions - are the most prevalent diseases on the planet. And we're not talking about some complex, mysterious disease. These are microbial infections. We have tools to detect them early and interventions that work (at least work well enough to make a major dent). Misaligned incentives don't motivate anyone to adopt these technologies or encourage preventive care.
Anyway, that's my rant. There are lots of things I didn't cover but I have to get back to work. Linking [my company here](https://www.bristlehealth.com/) to minimize self-promoting but provide some more info.
My Swedish public health care dentist removed one of my wisdom teeth when I was 18 since "it'll have to come out eventually and from next year dental isn't free for you so might as well do it now"
My Japanese dentist has also continually kept pushing for me to remove one of my wisdom teeth since "its hard to keep clean down there"
It is above all a changing thing. Everybody seems to be coming around to the idea that you don't have to routinely remove wisdom teeth, but it's still commonly done in Belgium and probably other European countries as well.
> It is above all a changing thing. Everybody seems to be coming around to the idea that you don't have to routinely remove wisdom teeth, but it's still commonly done in Belgium and probably other European countries as well.
No... You say that everybody is "coming around to the idea that...", which makes it sound like people used to believe that you should routinely remove wisdom teeth and now that's changing. No, in Europe this was never common belief. So people aren't "coming around to the idea that..."
The operation is just too slick from a business POV. As someone familiar with SaaS or in general this kind of recurring business model, you can sense all the little operational policies and procedures designed to increase your LTV.
It's a well-oiled machine. Without fail, the hygienist recommends cleaning not once every 12 months or even every 6 months, but every 3 months. When pressed on why, eventually they'll admit it's how nice it feels to have clean teeth and how important your smile is - but NOT strictly necessary for health.
This particular dentist also will shut down and take their entire staff to a resort for a week every winter if the team "hit their targets" for the prior year. That's the literal phrase they used to explain the trip. When I asked what those targets were, the person turned bright red.
So dentistry has a trifecta of factors that will encourage dark-patterns: (1) a true health-related reason for going both preventatively and to deal with problems; (2) a cosmetic / vanity-related reason (white teeth), and (3) the air of higher-educated medical authority.
Wrap that all in a lucrative recurring business model and of course it's going to lead to people taking advantage or at least overpaying for what they really need.
Just writing all this out made me realize I shouldn't be going to my current dentist! Thanks OP. :)