Fasten your seat-belt, this is an unabridged introduction to the topic of dentistry in the United States and my personal take on it. 🙂
We discover early on in dental school that a patient’s perception of good dental care has little to do with the quality of the care they receive. Considering most people visit the dentist specifically for good oral care, that is a startling thought. But when asked, most patients place the greatest importance on three things:
- How much a procedure hurts
- How much it costs
- How long it will take
Other important factors cited by patients are “friendliness”, “being on time”, “cleanliness”, “convenient hours”, “works with my insurance”. When searching online and asking people, rarely if ever do I hear, “good quality dentistry” or “conservative dentistry” on the list of important qualifications. As dentists, we often find ourselves torn between what our patients want and what we think they should want. It is not uncommon to tell a patient they have a dangerous infection in their mouth but the patient only shows interest in fixing a chipped front tooth. These are the challenges we face, that is, to provide good care to a patient and still have a happy customer. But what really is “good care”? Even within the dental community, debate rages on the best methods and materials for dental procedures. By and by, a consensus known as the “Standard of Care” is reached, defined by what a majority of “competent” dentists in a community think is “safe and prudent”. This system, although mostly protective of the public, also stifles innovation and prevents change. This is especially true when potential changes translate to less income for the dentist. After all, dentistry is not just a healing art, it is also a business. So the hard reality is that dentists routinely grapple with a different kind of dilemma: on the one hand they do genuinely want to provide excellent dental care. On the other hand, they also want to make as much money as possible. The line has to be drawn somewhere, for even the best intentioned dentist cannot invest unlimited resources into the care of their patients.
Ultimately, it is a dentist’s own morals and ethics that navigate them through day-to-day dilemmas of good care versus maximum profit. Yet when the collective population of dentists in a community mostly decides one way is more acceptable than another, it becomes the de facto Standard of Care. Unfortunately, some things have become so commonplace that no one questions them at all. For example, why is it that the default frequency for dental cleanings is six months or less? Most dentists will tell you that it’s because the majority of patients benefit from this frequency and it is the standard in the community. But there are patients who do an exceptionally good job cleaning their teeth at home, have no history of cavities and exhibit no signs of gum disease. Is it not acceptable to decrease their cleaning frequency to one year? How about 2 years or even more? In some cases the answer would be ‘yes’; however, chances are high that even patients with the ideal situation described in the latter example get told, “We’ll see you in six months”.
Over my years in teaching and private practice, I have witnessed a wide range of behavior among dentists. Some have made me proud of the profession while others have left me speechless with despair and anger. Dentists can exert a great deal of influence on a patient for good or for bad. If they say a filling needs to be done, who’s to say it does or doesn’t except for them? Who will oversee their diagnosis or their treatment? How will the patient know it was done properly and that they were charged fairly for it? Sadly, it is not easy for the typical patient to find answers to these questions. Perhaps this is why some questionable dental practices go unchallenged and why patients continue to praise a dentist who might be doing them more harm than good. After all, a dentist really only has to make treatment comfortable, not charge too much and get the procedure done quickly for most patients to consider him or her “the best dentist ever”. They will rave to their friends and family about their exceptional dentist and write glowing reviews online about their skills and talents. All the while, they may be completely unaware about the actual quality of work that was done or the real dental skills and talents the dentist possesses. Over the years I have witnessed this disconnect first-hand; that is, the break between what patients perceive as good dentistry and what is, in actuality, good dentistry.
My enthusiasm for honesty and truthfulness did not start in dental school. It was something I discovered in myself from a young age. As a child, if I saw a stranger stealing something, I felt personally affected and angry. I would think about it for days as the vision of someone taking something that was not theirs churned in my mind. The instinct never left me as I matured into adulthood. Towards the end of high school, I was on a quest to find the right career, a plight many high school students contend with. A friend introduced me to a manager at a car dealership looking for new salespeople. I immediately pounced on the opportunity as a summer job with potential for more – my first real adult job. But much to my disappointment, I proved to be a rather lousy salesman. Within a few months it became glaringly obvious that my talents did not lie in car sales. Many times I spent over an hour with a potential customer driving with them around town as they toyed with the idea of purchasing the car. But at the last possible moment, when all that was left to do was actually purchase it, they would cite some compelling reasons for opting out. They gave reasons like, “I need to bring my wife here so she can sign the papers too.”. Other times they said, “Let me just use the restroom first.” Rarely did I ever see or hear from them again after they so politely excused themselves. It was a rare event for someone to actually commit to the purchase. I was not the only one to notice these disappointments. My manager called me in to discuss my obviously poor performance and coached me on how to close deals more effectively. He explained that I needed to tell the customers whatever they wanted to hear and I needed to overstate what could be delivered, otherwise there was little chance I could make a sale. In my naiveté, I asked if his advice didn’t amount to “lying”. He laughed and said, “Well, we started lying after they started lying.”. It was an epiphany of sorts. For the first time I realized that the stereotypical car salesman wasn’t actually born unscrupulous. The behavior of his customers shaped his behavior to maximize the potential to sell a car. As it turned out, telling customers the truth about how much the car will really cost them or how reliable it really was did not result in a sale. Telling them they look great in the car and they should buy today because the price will soar tomorrow…will. And so it is a symbiotic relationship between salesperson and buyer. Each pretends it is not the game that it is and each enforces the others’ behavior. But alas, the arrangement was not acceptable to my conscious and I elected to maintain my dignity. I knew I could not find success in a profession where dishonestly seemed to win out more than not.
I held a few more odd jobs before I found an opportunity in biotechnical research. As an intern for a local firm, I found genuine interest in the sciences. I applied to the University of California, Davis, where I pursued a degree in genetics. But all the while, I had a yearning for more than science. I wanted to experience the human element and to fulfill my desire for justice, not really knowing what that meant. As a twenty-something year old, I had energy to spare. Rather than attending fraternity parties, I attended a part-time police academy. What better way to pursue my side interests than to be a police officer. After several years, I completed my certificate which gave me the opportunity to apply for a job at the City of Davis police department. While it was no small task to complete the hiring process, I was eventually admitted on the force as a part-time reserve officer. It took literally thousands of on-the-job training hours to complete the field training program and become solo-certified. This meant I could roam the streets without a partner and operate like any other regular full-time officer. It was exhilarating to say the least – a childhood dream come true. And in my ten years with the police department, I found myself satisfying that desire for justice and helping my community.
From there, life continued its twists and turns and I found myself in dental school at the University of the Pacific School of Dentistry in San Francisco, California. The rest was more or less history, but what carried over into my dental profession was a better appreciation of the need to protect the public. Whether it was not lying to sell a car, helping someone who called 9-1-1 or simply telling someone they did not really need a cleaning every six months, all of these had the same things in common: protecting and helping the average person without contaminating it with the desire to make more money. I always believed that the money would come naturally. But my first priority was to tell the honest truth and let the other side make their own choices. As long as I believed in what I did, I was certain things would work out fine.
Dentistry is a Business
The reality of private dental offices is that they are for-profit businesses. As such, most dentists are not engaged in just rendering dental care, they are also constantly trying to maximize their profits. And they need to maximize those profits for good reason: Between salaries, equipment, repairs, utilities, insurance premiums, supplies and taxes, the average dental office overhead is staggering. Although the number varies based on location, student loans, etc, a 80% overhead is not uncommon. This means that the dentist takes home less than 20 cents for every dollar of dental care produced. My alma mater is now charging about $100k per year tuition plus other fees, which brings a recent dental graduate’s debt to over $400k. Yes….you read that right. It should also be considered that while many people started working right out of high school or college, dentists spent four years paying tuition and not drawing a salary. So by the time everything is said and done, the actual profit a dentist takes home can be far less than what the public assumes. That explains why dental care can seem expensive and gives an understanding for why profit margins are a big motivator for most dentists. Unfortunately, it would bother the average person to know that the very act of maximizing profits can directly compete with the quality of dental care delivered. The balance between profit and honest care can be challenging and it’s a fine line that is easily crossed.
So why would I create such a site considering I am a full-time practicing dentist? The simple answer: because I have already been practicing this way for years and I will not make less money as a result of you reading material here. I also think that we as dentists have much to gain by ending the practice of money-driven recommendations and to start thinking critically about our treatment plans. A good, ethical and honest dentist has nothing to fear in this site and can only benefit from it.
The Science of Dentistry
When I evaluate dental products and techniques, I look at the science behind them. But at some point, we have to use good judgment and think critically about that science available. For example, when a new study emerges saying eating fresh home grown vegetables is beneficial to your health, there is a lot of good sense in that. Vegetables contain countless minerals, vitamins and other nutrients which study after study have shown to be beneficial. I have no inherent reason to doubt the science adding to that evidence. I also don’t question the motives of such a study, because even if it causes you to eat more vegetables, it won’t lead to one company profiting over another. As such, the author of the study is also not likely to profit from publishing it. That’s not to say the study was done properly or that it actually provided proof of anything, but the conclusion itself doesn’t set off alarm bells in my mind.
Conversely, a study that claims a specific supplement helps you lose weight automatically raises suspicion. Unlike the first study on vegetables, this latter study stands to profit from the conclusions. After all, if the study shows weight loss is achieved, you will go out and purchase some. This also brings up the all-important topic of funding. It is important to ask who funded a study, because the results could affect their bottom line. This is why I tend to automatically dismiss any study that is funded by the same company that could benefit from the conclusions. In the case of weight loss, most of the advertisements print something in small letters that says “results may vary” or “effective when combined with a healthy diet and exercise plan”. But one has to ask if the study proving weight loss with the supplement also showed the identical weight loss without the supplement under the same conditions (with a healthy diet and exercise). I would guess the results with or without the supplement would be the same, but the company conducting the study would not publish it if it included this fact, of course. My good judgment tells me to be wary of the study’s claims due to these unanswered questions and by the fact that the study was funded by the company selling the product.
Occasionally, ads try to confuse the public by claiming a study was done by an “independent lab”. This gives the impression of impartiality. Again, good judgment and critical thinking should make it clear that the so-called “independent lab” was paid by the company profiting from the results and specific findings from the “independent lab” are to be expected. Who’s to say that unfavorable results would be disclosed to the public? In reality, only the results that make the product look favorable will be shown. For example, say an independent lab did a study of 1,000 people using the weight loss supplement, but they found that only 10 people actually lost weight. The sponsoring company could handpick only those 10 and use their own customized criteria to dismiss the other 990 people from the study. Now they could advertise that their supplement caused weight loss in 100% of people who used it. Of course the reality was that closer to 1% lost weight. Also, was everyone on the same exact diet and exercise program during the study? What was the age range of the participants? When it is claimed they lost weight, how much was lost relative to their actual weight? If someone lost 10 pounds using the pill but weighed 250 pounds, this is not very significant (4%). On the other hand, someone losing 10 pounds who weighed 120 pounds would have lost 8%, a big difference. Also, who analyzed the data? What was their expertise and agenda in the matter? Was the study “randomized and double-blind”, meaning neither the participants nor the data collectors knew who was using the real supplement and who was using a placebo? Without this kind of in-depth analysis, any study could be used to conclude just about anything.
One would assume that dentists and doctors are immune to this type of manipulation by pharmaceutical and dental material companies. After all, anyone who goes to medical or dental school must be a superior analytical thinker with the background and knowledge to make informed decisions on our behalf. But this couldn’t be further from the truth. Doctors are no different from anyone else, and in some cases make worse decisions than the general public. The predecessor to Warren Buffet, stock market guru Benjamin Graham said, “…medical men have been notoriously unsuccessful in their security dealings. The reasons for this is that they usually have an ample confidence in their own intelligence and a strong desire to make a good return on their money, without the realization that to do so successfully requires both considerable attention to the matter and something of a professional approach to security values.” (pg 120 Intelligent Investor). In essence, sometimes doctors think they are so smart that they don’t stop to think about things critically and to be humble about their actual knowledge. They are not immune to this short-coming when looking at financial information and medical topics alike. This is why the pharmaceutical industry spends so much money promoting their drugs to both patients and doctors. In 1996 the industry spent $11.4 billion advertising, and this grew to $29.9 billion in 2005. The growth in direct-to-consumer advertising increased by 330% over that time and that was only 14% of total promotional expenditures in 2005. Why would the pharmaceutical industry spend so much money on advertising if those ads didn’t work? Although one would assume that a smart, competent and well-trained doctor would make recommendations to their patients based on good science and experience alone, these statistics cast serious doubt. The reality is that 71 percent of family physicians believe that direct-to-consumer advertising pressures them into prescribing drugs that they would not ordinarily prescribe. There is little doubt that the pharmaceutical industry affects doctor’s decisions, so much so that websites like www.nofreelunch.org have cropped up. These target the fact that doctors are so heavily influenced by advertisements targeting them and their patients that it affects their decisions and the ultimate outcomes of those treatments. In the best case, the cost of healthcare goes up. In the worst case, a patient receives less appropriate treatment and suffers consequences. Dentistry, unfortunately, is no different. While it is less influenced by drug companies, it is significantly influenced by companies that sell them products used in dental treatments. The ads are big, bright and beautiful. They claim to help the dentist do a procedure that once took 2 minutes and cut it down to 30 seconds. They claim it will save them money, their patients will like how it looks better and it will all be done with less pain. Are all these products actually better for the patients? Do they do everything they claim to do? In many cases, they do not improve upon a less marketed material and sometimes they are even worse.
An Example of Dentistry as a Business
When dentists place a white filling in a tooth, there used to be many steps to this process. So-called “Fourth generation bonding agents” involved the following steps: after the decayed tooth was cleaned with a drill, the surface was cleaned with a mild acidic solution for 15 seconds. Then a chemical known as a “primer” was applied and allowed time to soak into the pores of the tooth. Then another layer of “adhesive” was applied which ultimately formed the bond between the tooth and filling material. A special curing light was applied to this layer for about half a minute to cause it to harden. Finally, the hole was filled in small increments with a white material known as “composite” or “resin” until it was fully filled in. With each layer, the same curing light was applied for 60 seconds. Taking about 10 full minutes to complete, this was considered by many dentists as a lengthy and arduous process but it was very effective at tightly bonding the new filling to the tooth. But dental material companies began to combine the primer and adhesive into one tube to make it more convenient for the dentist and this was known as “Fifth generation” adhesives. Some dentists felt this was still too cumbersome and wanted more steps cut out of the process. Manufacturers responded by including the acid step with the primer/adhesive, a so-called “self-etching” system. This was referred to as a “seventh generation” product and now all the steps listed above for Fourth Generation adhesives was packed into just one step. Unfortunately, the end result was an inferior product to the “older” products even though they were and are touted by manufacturer as cutting-edge time-saving and money-making technology. Yet, the average dentist may not take the time to evaluate these products critically and will be swayed by the slick sales representative’s promise of cutting down treatment time and reducing the number of steps to the procedure.
[American Journal of Dentistry (April 2006, Vol. 19:2; pp. 111-114), Dental Materials (July 2000, Vol. 16:4, pp. 285-291), Dental Materials, “The clinical effectiveness of two-step etch-and-rinse adhesives was less favorable, while an inefficient clinical performance was noted for the one-step self-etch adhesives” (September 2005, Vol. 21:9, pp. 864-881].
Discussion of the Above Example
A typical patient would assume their trusted dentist would not use inferior products just to save some time and money. And most patients would probably agree that they would rather spend a few more minutes at the time of a filling and have that filling last longer than the alternative scenario. But the reality is that 7th generation adhesives are increasing in popularity. The answer largely lies with motivation. A typical dentist is motivated to provide you with good dental care and to do no harm to you (the Hippocratic oath). I believe the majority of dentists are well-intentioned. However, as previously discussed, a dentist is also a business owner and they are motivated to make more money. It’s helpful to consider a few scenarios when looking at how this affects a dentist’s decision. Say a dentist is offered a 4th generation product to do fillings and it takes 10 minutes longer to use when compared to a lower priced 7th generation product. And let’s say the dentist is largely unaware that these newer generation products are inferior to the older products or reads in non-peer-reviewed journals that the product is good. It makes sense, after all, that “newer is better”. Wouldn’t they obviously use a 7th generation product? Naturally they would. But what if the dentist was somewhat familiar with the peer-reviewed literature, and they were aware of its potential inferiority to 4th and 5th generation bonding agents? It presents a dilemma, for on the one hand, they know an older generation product might indeed work better but it will cost more to buy it and it will take up more of their precious time to use it. And what would be the disadvantage to that? Perhaps the filling would not last as long before needing to be replaced. How long should a filling last anyhow? Most dental insurance companies consider a filling lasting 2-3 years a success. So the dentist might make the following calculation:
- Use a 4th generation product that has a proven track record to bond better and last longer than subsequent generations. It will take longer to use and cost more to buy.
- Use a 7th generation product that has a questionable (if not inferior) track record, costs less to buy, takes less time to place but requires more frequent replacement since it is inferior. As long as it lasts the insurance-minimum of 2-3 years, then they would have fulfilled their obligation to the patient, would they not?
From these two options, it is easy to see why even the most honest and ethical dentist would be tempted to go with option 2. After all, the patient will never know the ins-and-outs of dental adhesives and will never question the longevity of a filling anyways. Heck, patients typically can’t even remember when a filling was done in their mouth. Unfortunately, the dentists that are both informed and stick to the better product are generally not rewarded. In fact, they may even be punished in a sense, because the patients themselves want their procedures done as fast as possible. Who wants to spend an extra 10 minutes in the dental chair? But perhaps being “rewarded” by the patient for using the right materials and taking the right amount of time to “do it right” is not necessary. A patient should not “reward” a dentist for being honest and ethical. That is simply expected. But at the same time, patients don’t “punish” dentists that are less honest and ethical. That’s because most patients will never know the difference. After all, as long as it doesn’t hurt, it doesn’t cost too much, it doesn’t take too long and the doctor is nice, they feel like they received excellent service from a wonderful office. That’s not to say that every dentist that uses a 7th generation adhesive is unethical or dishonest. But if they were aware of the literature and were convinced that 4th generation products were better, what could they possibly say to convince their patients it was in their best interest?
Wouldn’t it be nice if patients could look beyond the superficial niceties of a dental practice and independently assure themselves that the services they received were of the highest quality? Surely, most patients would figure it out if they only had the tools to know. What difference do those materials make in the real world? How long should a filling last? How can I tell if my tooth was fixed correctly? These are questions rarely answered honestly because, unfortunately, honesty equates to reduced profits in many cases. That’s not to say there aren’t amazingly ethical, honest dentists out there with the highest standards and the best intentions. There are dentists that place their profits behind good patient care. But it does take homework and it does require you to forcibly remove the blinders. A beautiful office and friendly doctor and staff is not enough. Having modern equipment, complete with lasers and “crown in a day” machines also does not assure good quality and success.
As for my opinions on what the honest truth is: these things are like politics. There are differing opinions on every topic. Both sides of the isle often point to evidence that they are the ones who are, indeed, correct. But typically, things are not so black and white. Much of it simply comes down to a personal decision based on the information at hand, our upbringing, personality and our individual circumstances. Many of the topics that are discussed here have been studied extensively, some have been written about in books and others discussed by the smartest minds in the profession at conventions and courses. No one person, and certainly not me, has all the answers. That’s partly because the answer is always changing. What dental medicine was sure about yesterday may have already been debunked today. I remember when lard was used to make fast food French fries. Everyone decided lard was bad, so a new healthier vegetable-derived fat was used: partially hydrogenated vegetable oil (margarine). Then the medical community concluded this was also bad and now non-hydrogenated blends are used instead. Many doctors wrote about the health benefits of margarine and today that would be considered quackery. It is these humbling lessons that make posting to this site so challenging. For every opinion I hold, there are studies supporting and deriding it. How do I know for sure I am correct? Is it when all the other doctors in the community agree with me? Is it when the newest studies, the majority of studies or the best-done studies do? Maybe I can only be proven correct when time proves me right? Can it even be proven at all? If I hold back on stating my opinion except when the vast majority of studies and other doctors agree with me, am I necessarily doing anyone a favor by regurgitating that here? Perhaps what the average dental consumer wants is nothing more than honesty and a reasonable opinion. So let’s get started…