J. Peter St. Clair, DMD Blog
Is Dentistry Becoming a Commodity?
November 3, 2011
There was a time when it would have been unusual to see an “advertisement” for a health care professional. In dentistry, dentists used to be able to hang out a shingle and patients would come. Today, it is the opposite. We are bombarded with advertising and it is very rare to see a “from scratch” practice open.
Times change, and that is okay. My concern is that dentistry and the dental profession are moving towards a more commodity-based service and away from a relationship-based, well-respected profession.
It used to be that dentists were among the most respected professionals. Dentists always received high marks for honesty, including high ethical standards, and trust. Today, those numbers are dwindling. In our newer consumer-driven society, the dental professional is seen by more as a provider of goods and services rather than as a health professional attempting to build long-term relationships with patients.
Technology is partly to blame for this. Technology is the step forward in dentistry. Today we have the ability to use better materials that are prettier and faster to deliver. However, these same improvements in dentistry are also being used as marketing tactics for dentists. Advertisements, in print, radio, television and the internet for specific procedures are driving the profession to a more commodity-based service.
Low-cost dentures, same-day crowns, and discounts for specific procedures such as Lumineers or veneers are among those things being advertised. When is the last time you saw an advertisement that touted building a relationship based on mutual respect and trust? It is my opinion that we are headed in the wrong direction.
Dentists are small business people. We need to have a healthy business to continue to provide quality care. However, most of the things that are marketed to us have to do with how to run a business or how to perform more procedures in less time that result in greater profits. Rarely do we receive materials that promote learning how to help us better meet our patient’s needs and build relationships. It is up to us as individual dentists to maintain a proper balance between providing ethical treatment and the “selling” of our services.
Dentists and other health care professionals require an accumulation of a large amount of knowledge, extensive institutional and clinical training, and testing of competency and skills. It is with all of this training that we are then obligated to follow a certain code which in part reads, “The Association (ADA) believes that dentists should possess not only knowledge, skill and technical competence but also those traits of character that foster adherence to ethical principles.” The term “profit” is not mentioned anywhere in the code.
As I stated earlier, dentists are small business owners and need to make a profit for us to survive. However, we need to work harder to maintain a balance between potential financial rewards and professional and ethical care. Only doing what is in the best interest of our patients will move us in the right direction.
But I Have Dental Insurance
October 14, 2011
It should come as no surprise that the insurance industry is out to make a profit. It’s a business just like any other business. Any place an insurance company can cut costs or deny a claim is more of a profit to them and that is their goal. Unfortunately, this is not always in the best interest of the patient.
When my son was born 15 years ago he could not keep anything in his stomach. We went through a battery of tests to determine the problem. Not once did I think, “I wonder if the insurance is going to cover this?” When the diagnosis was made and it was determined that surgery was needed when he was only 10 days old, not once did I think to check with the insurance company to see if it would be covered. When all was said and done the insurance company said that we owed $10,000. I had the normal reaction that anyone would have – How could I owe $10,000 when I have insurance?
Dentistry is a little different. There are not too many situations where a life or death threatening has to be made or the dependency on insurance coverage needs to be assessed immediately. Many dental insurance companies suggest that a pre-determination of benefits be submitted prior to any work being done. The reason for this is to control what is being done and to delay the payment of a claim. The longer an insurance company delays a claim the longer they have their money and they know that longer time periods lead to the possibility of the patient not following through with the work.
I recently had a claim rejected by an insurance company for periodontal scaling and root planning (a.k.a. deep cleaning). This is a procedure done on people with periodontal disease to remove calculus (tartar) and bacteria below the gum level. The claim was submitted with the necessary documentation showing clear evidence (in my professional opinion) of periodontal disease and the need for treatment. What does this say to the patient? The patient put trust in the doctor to make the diagnosis and suggest the necessary treatment but the insurance company basically said that the treatment wasn’t needed. Not needed? How do you explain that to a patient?
What happens if I say, “Your insurance company said that you do not need this procedure, so I guess you don’t need it?” Two things happen. One is that the patient does not get the treatment needed, determined by someone sitting behind a desk who has never even seen the patient. The other is a huge increase in liability. When the patient’s periodontal disease continues and the person ends up losing teeth, who is responsible? You would logically think that it would be the insurance company who denied the treatment. This is not the case. The ultimate liability falls on the dentist for not managing the disease.
Patients need to be educated on their conditions. We live in an insurance dependent world. Just remember – your insurance company doesn’t care about you the same way your doctor does.
How To Choose A Dentist
October 13, 2011
One of the many reasons people do not get the care they need is because of lack of trust. Whether it is the dentist, the doctor, the hair stylist, or the car mechanic, we generally seek out individuals who we like and thereby trust to provide a service for us.
I always ask new patients of mine how they decided to come to my office. The responses I get are probably the same for most dentists. The top ones are referrals by a friend or family member, the phone book, and more recently the internet.
I used to think that the only reasonable way to pick a health-care provider was from a referral of a friend or family member. Although, I do not think it is a bad way, I think the best way involves a little more research on the part of the prospective patient. Your best friend may have a dentist that she absolutely loves, but they may not be the right person for you.
So, how do you choose a dentist? Personally, I think it is very difficult. Trusting the dentist tops the list for satisfied patients in feedback surveys. You don’t have to be skeptical of every person’s trustworthiness, but I do think that prospective patients should sit down and have a conversation with any potential dentist or doctor prior to becoming a patient. It doesn’t matter where the dentist went to school or how long they have been in practice. What does matter is that you are comfortable with the people in the office.
It is impossible for a prospective patient to accurately judge a dentist’s technical competency. And although trust is essential, it has nothing to do with technical skills. If it did, then the most competent doctors would always be the most trusted. A key component is always not what was recommended but the approach and emotion behind how it was presented.
If the cost of service is the only thing that is your determining factor in choosing a dentist, you will not learn much about the dentist by asking questions about fees. Fees in any one particular office are based on many different factors. These factors include the level of training of the dentist, the quality of the materials and laboratories used, and the expenditures involved in running a small business. The amount and type of continuing education a dentist takes is very important and often reflects the quality of care they provide.
As a consumer, your search should begin with determining your objectives. Are you looking for a short-term relationship and inexpensive way to fix an immediate concern or a long-term relationship to partner in achieving optimum health? Although many patients choose their dentist based on whether they take their insurance, for reasons I completely understand, it is not the best way to find the most appropriate dentist.
The last step is to make an appointment with the dentist to just talk and discuss your concerns. This can be a 30 minute appointment with or without x-rays, just to get a feeling for the office and dentist. Most dentists will not charge a fee for this visit.
There is no one dentist who is right for everyone. Use the same criteria for choosing a dental office that you use in choosing any other service. You’ll know you are in the right place when you feel a mutual level of respect and your individual concerns are addressed in a caring, non-pressuring manner. Good luck and I encourage any questions you may have.
The Transitioning Practice – Part 2
October 3, 2011
Last week I began talking about what to do if your long-time dentist is replaced by someone new. Having taken over the practices of two retiring dentists, I consider myself pretty experienced at this type of situation. Let me see if I can break this issue apart.
For those long-time patients, change is not easy. My theme of last week’s column was that you owe it to your retiring dentist and the staff to give the new dentist a try. From there you can make the decision on whether you are comfortable or not.
In my last practice transition I was taking over an office that was stuck in the 1970’s in both style and equipment. The patients loved it there….and they loved the “retiring” dentist. Enter me. I went in and replaced all the windows, floors, cabinetry and equipment. I did it for the patients but I also did it for me because I needed to be comfortable in the place I was working.
I got many comments about the new digs. Most people appreciate when things are “state-of-the-art” and in this case desperately in need of an update. However, that is a just a small piece of the puzzle.
Long-time patients of a dental practice grow very attached to their dental office. This includes the dentist and the staff. The transition of a dental practice is often the excuse patients need to switch if they have been traveling a long distance to see their dentist. Patients definitely find comfort in at least seeing the same faces of the staff when they return to the “new” office. Therefore, it is very important for the “new” dentist to keep the same staff, at least for a while.
However, as the leader of a dental practice and a small business owner, the dentist will undoubtedly make changes. These changes, from my own experience, are made for both the benefit of the practice and the patients. This can be difficult for many patients to understand as most only visit the office a couple of times a year. When a patient sees a new face and familiar faces gone, it always raises questions. The entire current staff of the office needs to be comfortable with discussing the changes. Although uncomfortable, patients should not hesitate to ask any questions they have.
I have been very lucky in both of my practice transitions to retain the majority of existing patients. I understand that choosing a health-care provider is a very personal decision. When a practice transitions, the patients are automatically granted a “new” dentist without the initial ability to choose. The bottom line is that you always have the right to choose your health-care provider.
Patients should know that most providers respect a patient’s right to choose. Yes, it is always a little depressing for the staff to see long-time patients leave. However, it is also very gratifying to see a practice family grow as new relationships are made.
In conclusion, give your new dentist and dental staff a chance. You may be pleasantly surprised. If not, move on. If you aren’t comfortable for whatever reason you always have the opportunity to go back “home”. Most offices welcome this.
Next week I will discuss some ideas for finding a new dentist should you decide to transfer. This information will also be helpful for those who have not been to a dentist for a while or are new to the area
The Transitioning Practice – Part 1
September 27, 2011
It has happened. The worst possible thing in the world you could ever imagine has happened to you. The dentist you have been seeing for the last 20 years has retired. What are you going to do?
Many people, including myself, get attached to their healthcare providers. When you build a relationship with your healthcare provider and the office staff, there is a level of comfort in knowing that when needed, there is a person/office you trust to take care of you. When that provider retires there is a sense of abandonment, obviously not intentional, and that feeling of – What do I do now?
In many cases, the staff members remain, which is not only important for the patients, but also for the new provider. Dental patients go to a particular office for many different reasons. Those reasons range from convenience, insurance coverage (which is not necessarily a good reason and a topic for its own column), they love their hygienist and the other staff, they believe they are getting the best of care, or they have just developed a sense of comfort with the office. I can tell you a fact that I have seen over and over again – no matter how good the dentist is, if patients have issues with the staff, they don’t stay. Staff members play as much of a role in patient retention as the dentist does, if not more. If the staff members leave with the retiring dentist, it can be that much more devastating for patients.
The fact that your dentist retired obviously means that you must have a new dentist, whether you stay with the office or you decide to go to a new office. Because of this, and especially if familiar faces remain, it is usually a good idea to give the incoming dentist a try. One thing is certain, regardless of whether you remain in the office or jump ship, things will be different.
Every dentist has their own unique personality, style of practice and philosophy of care. It is unrealistic to think that any one dentist will be the same as another. It is impossible for you as a patient to have any way to evaluate the clinical skills of any dentist……although most patients don’t even think about that. For patients, the first thing you will be looking for in your new dentist is whether or not your personality meshes with the new person.
Expect to hear new things. As I said, every dentist is different and has his/her own unique style of practice. It is up to the dentist to be able to communicate their philosophy of care with you. If they fail to do this it is their problem because you will not be staying.
In general, a retiring dentist has been in practice much longer than the new person coming in. Patients get used to the style of practice they have been in. You need to keep an open mind. I know we have been inundated recently with the notion that change is good. My philosophy is that change can be good.
It will be up to you to decide if this particular change is good for you or not. If you approach this change with an open mind, and your new provider communicates his/her philosophy well, it will give you the best opportunity to decide if it is right for you.
I will present a few more ideas on this topic next week.
The Silent Epidemic – Part 2
September 21, 2011
Last week we discussed the role and effect that diabetes has on oral health. It is not something that should be taken lightly. If you missed this column, please visit the website at the end of this column or e-mail me directly and I will send you a copy.
After reading last week’s column, it may seem frightening that there is no way out of the partnership of horrors between diabetes and severe gum disease. There are solutions. Just as poor oral health can compound a diabetic’s plight, proper oral health can come to the rescue.
Clinical studies confirm that treatment of gum disease reduces oral inflammation, which removes the factor that triggers the body’s inflammatory response which, in turn, plays a major role in compounding the effects of diabetes.
Dental treatments that fight gum infections also help improve control of blood sugar levels in diabetics.
If you are pre-diabetic, your dentist may actually be able to help prevent diabetes. If you already have diabetes, your dentist may be able to help you keep it under control, improve your quality of life and reduce the risk of premature death.
There’s even better news. It’s never too late to improve oral health care. Even if you already have severe gum disease or other dental problems, proper treatment can help stop it in its tracks. In many cases, dentists can even reverse the damage done to your teeth and gums as well as manage the metabolic elements of diabetes. And, if you haven’t yet developed any symptoms of diabetes-related oral health problems, your dentist can start a prevention program that will help you stay in control of your diabetes, maintain better health and enjoy a preferred quality of life.
Perhaps the best news is that this is something that doesn’t require exercise, taking a pill, giving yourself a shot of insulin, or sticking to a special diet. However, some or all of these things may be necessary to also help control diabetes. From an oral health perspective all you need to do is to start seeing your dentist and talking to him or her about your particular situation.
In the dental world there are going to be varying degrees of participation from dentists, depending on their knowledge or “philosophy” of care, when it comes to partnering with you to manage the oral health issues in regards to diabetes or pre-diabetes. Different dentists just practice differently. The best team approach is between the doctor, the patient and the dentist. If one of these team members does not participate, the battle cannot be won. Often times it is the patient who is not doing the things that he or she needs to do to properly manage the problem. If the dentist does not seem too concerned about your diabetes, you have the desire to have your oral health properly managed and are willing to do your part, find a new dentist.
The point is that this is a serious issue and if you, the patient, wants to take control of it, a team effort is needed.
The Silent Epidemic
September 8, 2011
With more than 24 million diabetics and 57 million pre-diabetics in the United States, nearly a quarter of the nation’s population has already been affected by this disease. The connections between dental health and diabetes have never been more critical.
As an indication of our general health, the rapidly rising rate of diabetes should be ringing alarm bells everywhere. The litany of health implications from diabetes is a long and grisly list. It is the sixth leading cause of death in the U.S. That is probably vastly understated because as many as 65% of deaths from diabetes are attributed to heart attack and stroke. People with diabetes have about twice the overall risk of death as those who don’t have the disease.
Complications from diabetes cuts years off productive lives and interfere with the quality of those lives through a host of debilitating health effects. Heart disease and stroke rates are as much as four times higher among diabetics. Nearly three-quarters of diabetics have high blood pressure. Each year, diabetes causes blindness in as many as 24,000 Americans. It is the leading cause of kidney failure, nervous system disease, amputations – the list goes on.
This isn’t meant to be a scare tactic. These are simply the facts and, yes, they are sobering. But if you have diabetes or are pre-diabetic, you may want to brace yourself. Because we are going to talk straight about oral health and diabetes, two diseases that can twist each other into a tight downward spiral of amplifying negative health effects. Unless they are halted by your physician and your dentist working in tandem as a health care team, together with your commitment to hold up your end of the bargain, these effects can continue to compound.
The facts about the connections between oral health and diabetes are even more alarming than those about diabetes alone. Here are just a few:
Diabetics are twice as likely to develop gum disease. This is especially true if your diabetes is not under control. The gum disease then worsens your diabetes through an automatic response that your uses to fight the infection.
People with gum disease are 270% more likely to suffer a heart attack than those with healthy gums.
People who have diabetes and sever gum disease have a premature death rate nearly eight times higher than those who do not have periodontal disease.
Those who have gum disease and diabetes together are more than three time likely to die of combined heart and kidney failure.
In people who have type 2 diabetes, gum disease is a predictor of end-stage kidney disease.
In people who have pre-diabetes – blood glucose levels that are higher than normal but not in the diabetic range – gum disease makes it more likely that they will become diabetic.
Once established in a person who has diabetes, the chronic infection that causes gum disease makes it more difficult to control diabetes, and increases damage and complications in blood vessel disease.
We will continue this discussion next week and talk about some things you can do to help this problem.
Room For Improvement
September 2, 2011
Dentists play a key role in screening patients for many disorders relative to nutrition and in providing appropriate referrals into the health care system. Although the importance of integrating diet and nutrition guidance into dental care has been advocated for decades by educators, it continues to be ignored except by a handful of prevention-oriented practitioners.
Many of the world’s most significant health problems are linked to poor dietary practices, including over-nutrition and under-nutrition. Nutrition plays a fundamental role in health, and dental professionals have the opportunity to be a critical link between discovery and wellness.
There is a great deal of evidence linking oral infections, including periodontal disease, nutrition and immunological response. We have clear evidence linking oral disease with adverse pregnancy outcomes, diabetes, cardiovascular disease and stroke. In addition, obesity, which is an epidemic facing our country, is significantly affecting the incidence of diabetes, cardiovascular disease and overall lifespan. We know there are direct connections between these problems and oral disease. What is the role of the dentist? Should the dentist just be a tooth fixer?
As the body of data linking systemic health conditions and oral infection grows, the expanding understanding of the gene-nutrient reaction may result in more profound discoveries. As of now, many dentists fail to fully appreciate that the scientific bridge between oral disease and systemic health is often mediated by diet and nutrition.
The beneficiary of this profound evidence should be you, the dental patient. It should not only be the responsibility of the physician or specialized nutritionist to incorporate this information into practice. The dentist should be playing a key role.
For the most part, the dentist is the only one who examines the mouth. It used to be that the dentist only looked at the teeth and only fixed problems when they arose. By now, most dentists screen for periodontal, or gum, problems as well as oral cancer. The trend is to address these problems earlier than ever before.
People tend to have ingrained in their head that the dentist just looks at the teeth and treatment should be the same as 25 years ago. The fact of the matter is, things change. As I have said in numerous previous columns, there are no two dentists that practice identically. Each individual’s philosophy of care comes from personal experience, review of literature and the type and amount of continuing education taken. One thing we all hope is that our health care provider, dentist or physician, has our best interest in mind. There is room for improvement in the communication between all health care providers.
As science continues and evidence grows, preventative care and treatment will change with the times. It is the responsibility of all health care providers to work towards a more integrated health care system.
Should Amalgam Be Banned?
August 30, 2011
I was reading a recently published report entitled “Economic Impact of Regulating the Use of Amalgam Restorations”. The study looked at the effects a ban on the use of dental amalgam (mercury/metal fillings) would have on our society.
Dental caries (decay) is still a widely prevalent oral disease in all ages of the population. Amalgam has been used for more than 150 years for filling back teeth and is composed of a mixture of silver, other metals, and mercury (50% by weight). As of now, the other options for filling teeth include composite resin, porcelain materials, and gold.
One of the concerns with the use of dental amalgam is that increased mercury levels for extended periods of time are associated with neurological, renal, and immunological impairments. It is known that amalgam restorations release mercury vapor during chewing, and that people with amalgam restorations have slightly elevated urine mercury levels. Another concern is the environmental impact that mercury has when it is disposed of from either excess filling material or removal of the material from teeth.
Although amalgam use is declining in the U.S., it is still widely used. Several countries, including Germany and Norway have limited the use of amalgam to adults and non-pregnant women. Denmark and Sweden have completely banned its use.
The debate in this study is the economic impact restricting the use of dental amalgam would have on our society. Materials other than amalgam are typically more expensive, and some of them do not have the same expected life-span of amalgam, which means they may need to be replaced more frequently.
Basically, the results of the study are as follows. Based on several studies, there is no evidence that the use of dental amalgam leads to any adverse neurological impairments. Likewise, according the report, the disposal of mercury from amalgam fillings is not a significant source of environmental mercury. Predictably, based on the increased costs associated with using other materials, lower-income segments of the population would be most affected by a limitation or ban on amalgam use. This in turn would lead to a higher prevalence of untreated dental disease.
If the studies show the stuff is reasonably safe and a ban would have a disastrous effect on a large segment of the population, it should not be banned. I don’t think the government has the right to limit one’s choice of what they fill their teeth with. Look at cigarettes for crying out loud. If the government wants to ban something ban those. We know those are unsafe. Actually, I do not think they should be banned, although I do agree with the limitation of use to decrease exposure to the rest of the population. If someone wants to smoke, knowing the risks, it should be their right.
Back to amalgam. I do not think there should be a ban on the use of amalgam, but I do think it is the right of the dentist to decide whether they offer it or not. It is also the right of the patient to decide who their dentist is and what is put in their mouth.
One more thing to think about….. if studies show that amalgam is perfectly 100% safe, why have the European countries I mentioned limited or banned its use?
Science or Common Sense?
August 16, 2011
Last week I started talking about how these new “squiggly” light bulbs we are all being forced to use by 2014 contain mercury. Because they contain mercury, they come with their own set of disposal instructions. Although I have not used dental amalgam as a restorative material for over 10 years, I can assure you there are no warnings on the packaging for this product before sticking it in your teeth…….and it is 50% mercury.
I had to replace a thermostat at home last weekend. The message below was strategically placed on a piece of paper to make sure it was not missed:
“Mercury Warning and Recycling Notice: Mercury is considered to be a hazardous material. If this product is replacing a thermostat that contains mercury in a sealed tube, contact your local waste management authority for instructions regarding recycling and proper disposal. It may be unlawful in your state to place it in the trash.”
Here is part of the statement posted on the website of the American Dental Association (ADA):
“Dental amalgam is considered a safe, affordable and durable material that has been used to restore the teeth of more than 100 million Americans. It contains a mixture of metals such as silver, copper and tin, in addition to mercury, which binds these components into a hard, stable and safe substance. Dental amalgam has been studied and reviewed extensively, and has established a record of safety and effectiveness.”
The FDI World Dental Federation and the World Health Organization concluded in a 1997 consensus statement – “No controlled studies have been published demonstrating systemic adverse effects from amalgam restorations.” Another conclusion of the report stated that, aside from rare instances of local side effects of allergic reactions, “the small amount of mercury released from amalgam restorations, especially during placement and removal, has not been shown to cause any adverse health effects.”
I don’t know about you but there are some things in life that I wholeheartedly trust science and research for and then there are other things where common sense takes over. Common sense tells me that if mercury has been taken out of all thermometers, and there are warnings on the packaging of all “new” light bulbs and thermostats, why do we still feel comfortable sticking a product that is 50% mercury in teeth?
Despite the fact that mercury vapor is released into the mouths of people who have amalgam fillings, the daily dose of mercury is not enough to cause concern with the ADA or anyone else. However, all dentists in the state of Massachusetts were mandated by the state to install and register an amalgam separating unit. When the filter needs replacement, it is considered hazardous waste and must be disposed of through a licensed waste management company.
Can a dentist advise a patient to have amalgam removed for health/safety reasons? The FDA has concluded that amalgam fillings cause no demonstrated clinical harm to patients and that removing amalgam will not prevent adverse health effects or reverse the course of existing diseases. So, although a dentist cannot legally advise you to remove amalgam fillings, he or she does have the right not to provide them as a service or require the use of certain techniques for their removal.
More next week.
