The 'Irrational' Way Humans Interact With Dentists
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He doesn't use X-Rays to find cavities, he's got this laser thing that directly measures the tooth density and makes little werping noises when it is low. He found a couple of things (which I had no reason to suspect weren't problems as they were highlighted as problem areas by another guy ten years ago, and one of the other problem areas he said still isn't enough of a problem to be worth doing). It seems a much more objective system than poking at things or looking at X-Rays. I got a couple of filling done via laser drill, which I didn't need anesthetic of any kind for. (Those with low pain tolerances might, it wasn't pain free, but it was OK and I preferred it to a droopy drooly mouth for most of the rest of the day.)
I figured I'd just been out of the game for a decade and a lot has changed but I've mentioned this to my coworkers and few of them recognized any of that stuff. Your anecdotes solicited.
But it's not a perfect system - detection is about 80% to 90%, http://jdr.sagepub.com/content/83/suppl_1/C80/T1.expansion.h...
Edit: ninja'd
Hmm, may I take this as further evidence that my absolutely terrible selection metric has indeed blundered onto a good choice? (I'm honestly surprised, I honestly thought I had just been out of the loop.)
Sorry to be coy with the name, it's my instinctive "protect other people's privacy" thing from being on the Internet too often. I forget "he" is also a business and that doesn't really apply.
6 month after moving to the bay area, I went to a local dentist for general checkup. He used the "laser thingy" to find cavities and found no less than eight cavities that required filling. He also took XRays that showed no issues at all. I asked him for copies of the records and XRays so I can send to my father for second opinion. He immediately agreed, but despite weekly reminders, he never sent me the films.
On my first visit back home, I got my teeth checked by my aunt again. I need one filling.
Lessons learned: * US diet accounts for one cavity. * Dentist greed accounts for seven more. * Always ask your dentist for copies of XRay and files and don't return if he will not supply them. It is your right to have those copies of your dental history. * If the XRays don't show the cavities, there are not at a level where you need to treat them yet. You can safely wait until they show up. If you maintain high level of dental hygiene they may never get to the point where they need filling.
Every time I go, I am absolutely floored by the prices. I haven't been for several years now as I've had no pain requiring immediate attention.
My last experience with dentists was getting a tooth that had cracked in half examined. At that point I had some pain, but I use sensodyne toothpaste so it seems to have healed over the crack. I can't recall the exact numbers, but I first had my regular dentist look at it, who then sent me to a specialist (oral surgeon I believe). I seem to recall the combined charge of these two visits was almost $1000 (this is in Canada, fwiw). Total time in chair was far less than 30 minutes....I recall calculating the hourly cost was >$2000/hour. The estimate on "building the tooth back up" (not pulling and replacing with ceramic) was around $3000-$3500 (for I think around 45 minutes work).
Teeth cleaning is less, but on an hourly basis, it is just ridiculous. And of course it seems to always come with the unrequested inspection by the dentist, < 5 minutes for $75 (likely much more now).
I just can't fathom how working class families without insurance can afford this....even for the parents, let alone their kids!
I know they have some expensive machinery to pay for, but I just can't see how these prices are justified in any way. Yes, I know prices are "set by the market", but I have never encountered any dentists that vary much in price, style of delivery, or services offered. I have also never encountered a profession so secretive about its prices. Receptionists never have a clue about what the price range would be to cap a tooth for example, it always "depends".
It would seem to me that doctors would likely have to take much more schooling, and they certainly have more advancements in their industry to keep up with, but in Canada at least, it is fairly common for a family doctor to make $150 to $200k per year. I reckon a dentist could easily make that in 3 months: $500/hour * 160 hrs/month * 3 months = $240,000. Yes, this is a simplistic calculation, ignoring the 4 dental hygienists working for him earning him $50/hr profit, possibly not 160 hrs/month billable (but equally possible billing equivalent of 260 hrs/month if he structures his staff right), must rent office and lease equipment, receptionist, etc etc....but you get the idea.
To me, something about the whole industry just doesn't seem right. It smells to me of collusion to some degree, but this is just pure speculation.
One other related thing I have noticed (anecdotally)....whenever you go to a dentist or doctor/clinic in Canada, there is always a big lineup, usually with at least a half hour wait, even with an appointment. The times I have visited a dental or medical office overseas (Thailand and Japan), there were either very short wait times, or I was literally the only person there....which makes me suspect the medical and dental associations here may be restricting the number of new applicants into schools, in order to control the supply of their services, and therefore the price.
Anyways, can anyone with some actual knowledge of the field could comment on my pure speculation?
Dentists don't like to quote prices because they want you to choose them based on their skills and reputation. Letting you shop around would turn this into commodity market. They do know (at least in countries without strange insurance habits) how much each procedure should cost and how much each of their friends asks for. This is not exactly collusion, but can contribute to price similarity. The same way that you can't find a decent DBA in the bay area for less than 100k. People usually know how much their skills are worth.
Hope this helped.
It is interesting how devoted most people are to their dentists. I was referred to a dentist who was TERRIBLE. Really really bad. And the person who referred me had referred a whole bunch of people who all went there (which is why I trusted the referral). I never went back, and started asking other people what they thought - everyone had doubts about his skills, but still went. This article is an interesting way of explaining why they kept going regardless of the terrible experience and lack of competence.
- technique (one of the most important, but generally difficult to interpret without some tuition. However some good indicators are time spent in mouth during procedures, how prepared is the dentist (hunting for tools is worrisome), level of pain, number of times work has had to be fixed)
- hygiene (appropriate glove changing, mask, tool use and sterilization). The most obvious things I notice are whether tools are coming out of sterilization bags and being placed on a sanitized surface. Does the dentist return a tool that's been in your mouth back to the sanitized surface?
- equipment (age of equipment, tech levels (not too high - don't forget, you the patient are paying for it). This is also important as digital x-rays use much less radiation and allow for immediate review with the patient.
- patient manner (attentiveness to pain and mouth discomfort, willingness to answer questions and properly explain procedures, or even minor things like accommodating patient embarrassment of tooth condition)
- upsell (does the dentist try to have you buy an occlusal splint without demonstrating actual tooth wear, sell you on cosmetic surgery, or attempt immediate intervention constantly rather than a wait and see approach)
- preventative methods (often, but not too often periodontal examinations, fluoride treatments, x-rays, etc)
Actually the operative word should be can use much less radiation. Because the sensors are digital, the software will auto-compensate for exposure levels. A study at my university by the physicists in the radiology department showed that the x-ray techs were often using much higher exposure settings than necessary on the digital setups, but no one was noticing. On film, overexposure would make the images unreadable, and it would have been noticed immediately.
A question you need to ask your dentist is, "how often is your x-ray equipment calibrated?"
Granted, you're getting much less radiation exposure at the dentist's than at the doctor's office, unless you're getting dental CT's.
Just for clarification, that tool SHOULD be going back to the sanitized surface correct?
My brother, who is a dentist, used both film and digital in school and found he preferred the resolution of film. No doubt digital will improve though.
1. The digital x-ray plates are rigid. He finds this deforms the soft tissue too much to show a good picture.
2. Scaling. With film, he can take a direct measurement at 1:1 scale off the image. With digital, the scale isn't 1:1 (and variable? I wasn't clear on that), making it more difficult to work with. One imagines this would be a simple problem to solve.
(The bad news is that we were discussing this as he was investigating a 9mm pocket at the root of one tooth. He says I'll at least need a root canal; likely lose the tooth and need an implant. He's sent me to my "regular" dentist for a 2nd opinion -- that gives me more trust.)
Then, when I came back from my first semester of college I had to switch from my old dentist (who specialized in children/teenagers) to a new one.
On my first visit, he identified something like 3 cavities, which was pretty shocking to me. Before I just assumed that the x-rays were easy to interpret so the dentist is 'always right' ... but after hearing about this 50% figure it makes me wonder.
For a while my mouth was effectively "Exhibit A" in some kind of professional complaints process.
My wife had a similar experience. We both grew up in a small city, and throughout her life she never had a single cavity. She prides herself on the health of her teeth.
In college we both moved to a larger city (which has a more competitive dentistry market), and suddenly dentists were finding cavities every time she went for a checkup.
While it's entirely possible that she didn't have cavities before, and now does all the time, I feel like the competitiveness of the market here has lowered the standard of what actually requires a filling.
That is, in our hometown, a dentist could take a more measured approach -- if something looked like it could develop into a problem but wasn't currently one, they had the leisure of waiting for the next six-month checkup to reevaluate. Here, it seems to be the equivalent of shoot first and ask questions later.
Also, every filling I've ever had never came as a result of actual pain or discomfort, they only occurred because I went in for a regular six-month checkup. Given my wife's experience (going from apparently perfect teeth to requiring fillings at nearly every checkup) I can't help but feel about as confident as a woman at an auto shop hearing "You need your blinker fluid replaced".
FWIW, I've heard that by the time you have pain or discomfort in association with a cavity, it means it has reached the nerve, which indicates a root canal at that point, rather than a filling. So, getting cavities filled before they hurt is important.
When you have a cavity, cold things that get into your tooth can set off the nerve and your teeth become sensitive. (If it gets worse you respond to heat as well.) This can be corrected with a filling. There are other causes of sensitivity as well, ask your dentist if you're affected.
When the cavity becomes bad enough that it touches the nerve, the nerve gets infected and you get intense pain. Antibiotics can temporarily help, but now you need a root canal.
If the structure of the tooth is compromised, or if the cavity cannot be operated on (happened to me with a cavity behind my back molar, under the gum - caused by damage from my wisdom teeth), then you need to lose the tooth. If your mouth is in good enough shape then modern dentistry allows them to fill in the hole with powdered cow bone, that will become real bone, into which a post can be driven and a fake tooth created.
Before dentistry, people didn't have any of this. What would happen is that their teeth would get to the point of needing a root canal, and then the pain would quickly become so bad that they'd do anything to make it stop. Anything was typically something like, Tie this string around the tooth, let me tie the other end to a door and slam it. People would start losing teeth around 20, and have lost all of them by 40 or so. Then they'd get dentures.
We still need dentures. But it happens much later in life than it used to. Some people never get them. This is a good thing.
A note about dentists. Dentists go to seminars on how to drum up business. There are a lot of questionable things they do. But if you show up with a mouth full of real problems, the competent ones should be able to prioritize them, coming up with a plan, and progressively fixing just what insurance will cover in each time period. At least that was my experience when I began going to dentists again after I could afford it.
You shouldn't pay your programmers to fix bugs or lay down lines of code, but to produce working software. You shouldn't pay your doctor to treat you, but to make and keep you well. You shouldn't pay your mechanic to fix things, but to make your car run. And you shouldn't pay your dentist to fill cavities, but to keep your teeth healthy.
The DoD calls it performance based logistics. We build a system and promise to fix it whenever it breaks. If it's working X well for Y days of the year, we get paid $$$. Otherwise, we get paid $$ or even $.
It just makes so much sense. It weirds me out that maintainence is handled any other way. It's just begging for vendors to take advantage of consumers who don't know any better by selling things that are useless or even harmful.
Don't see why dentistry should be any different. My auto insurance gives me about $8/mo off for having anti-lock brakes. My dentist could give me $X/yr off for brushing. (And he can tell...)
And of course, in general, I'm not trying to sabotoge his efforts. I want to be healthy as much as he wants to be paid. That is, after all, what I'm paying him for. If anything, it encourages him to encourage me to develop healthy habits.
If you could get over the admittedly uncomfortable social dynamic of implying a lack of competence in your dentist, you could ask them to send your Xrays over to "2ndopinion.com" where trained and certified dentists would give a second opinion. You might pay $80 for the privilege, and for that price maybe 2 dentists would review it.
Anyways, you get the idea. I love disruption around information disparities.
In either case, I doubt you'd find much traction since looking at dental x-rays isn't something most people are going to want to do on a regular basis without being compensated.
First, however, you would have to find out whether lay people are any good at this task.
The pathology report revealed that there was about a 20% chance I had papillary thyroid cancer, which has the highest cure rate of any type of cancer (>95% are completely cured after a thyroidectomy). So he recommended we take it out.
And that's what I did... a partial thyroidectomy where one half was removed. Turned out there was no cancer.
It was weird, though. After all of the painful tests, the long weeks waiting for appointments, the waiting in doctor's offices, the uncertainty, I didn't really think to say "Well, this is pretty low-risk... why don't we just wait on it?"
Surgeons will operate if you let them. It's what they do.
This interview just reaffirms my total lack of trust. It's like going to an auto mechanic. Setting aside notions of customer loyalty and karma, and what would happen if word ever got out, the auto mechanic maximizes their revenue by screwing over their customer.
"Well, of course they're trying to screw you. What do you think? That's what they do. They can make up anything. Nobody knows. 'By the way, you need a new Johnson rod in there.' 'Oh, a Johnson rod. Yeah, well, you better put one of those on.'"
All 6 were either dishonest or incompetent. Including: preventing my front teeth from meeting; modifying opposing teeth for a fit; key equipment not working; charging me for work not done (I was informed that they'd checked the invoice too); going back on an agreement (to give me the xrays); going ahead with work without asking me (I found it impossible to get out of the chair to stop him); and of course being overcharged (my accountant remarked on it.)
However, all 6 were excellent at minimizing pain, and that seems to be what most people notice. I'm more concerned about getting my teeth fixed.
The 2 previous to these 6 were not very good. I would have thought 6 more would be enough to find a good one. I have given up on the dental profession as institutionally corrupt. I do not believe there is even any facility to complain about them, as that would also be run by dentists.
Because it's difficult for a layman to check a professional's work, especially when that work is also difficult to inspect, I used secondary signals in the above. However, I also bought a small mirror, and a direct inspection also revealed a misplaced shallow drill hole (with no filling). I remember years ago one of the previous dentists had slipped, but I didn't think it had actually resulted in any drilling. None of the dentists mentioned this very obvious rogue drill hole.
I think most people are happy to get out of there, and if any pain stops. I just wish I could DIY my own dental work.
Can anyone suggest how I can find a competent dentist?
For people in the US, Yelp is a good starting point, but it helps to try a dentist once or twice as a trial (rather than going for major work without knowing what they're like).
Yeah, I've been doing the trial thing also. Maybe I should keep trying, but some were charging $100-200 for just inspecting.
As an example, as a child I was under government health care (Indian Health Service in the US) and "had to have" a root canal done. The dentist did the work (come to find out it is generally someone else who does this). I think nothing of it other than the extreme pain. This is when I was in 6th grade.
1st year of college and I get this incredible pain in my mouth. I go to a dentist (not IHS) and get my mouth checked. Come to find out the original dentist left some infected material in there and I am in a world of hurt. Antibiotics and Percodan for two weeks and then oral surgery. The oral surgeon had some not-so-kind remarks about the person who originally did the root canal.
Ha! My dentist actually said ‘This might be …’ as we looked together at a X-ray. He said that we could be looking at very, very early caries or just a shadow and that X-ray images are always tricky. I will be X-rayed again at the next routine checkup to see if anything has changed.
Incidentally, how common are X-rays in the US? It sounds like they are quite common which surprised me. They don’t seem to be part of the yearly checkup in Germany if I’m remembering right. I think it’s rather a every-other-year or every-three-years thing.
(and my dentist is the same way -- he'll sit down with an x-ray and sometimes photos as well, and go over "OK, this might be the beginning of a cavity, or it might just be a stain from drinking tea/coffee...")
Dentists will often drill and fill these dark spots "just to be sure". This is the first time I've ever really considered the financial angle and the perverse incentive that may also be at work.
The proliferation of digital xrays with instant networkable images creates a fascinating opportunity here. There's probably a startup in instant second opinions...
You might as well choose randomly from a phone book. That's what I did when I moved to a new city. Actually I looked for dentists that were close to me, that spoke English natively (I live in a very cosmopolitan city), whose dental degrees were more than 5 years ago (gained experience) but less than 20 years (not outdated), and whose staff were pleasant and prompt on the phone (on the theory that the behavior of the staff will reflect the character of the boss).
Thus I picked my dentist without a recommendation and without meeting or speaking with him, but I think my method is less arbitrary than asking your friends and co-workers. (And yes, I do wish there was a better way.)
I image, if I was to buy a car, I would look up interesting models on the internet (including price information), perhaps ask my friends for advice. When I am ready knowing what car I want, I'd go to the dealership, see if their price is right, and buy it (or leave it).
I might phone around before hand, to find out their prices and compare with other dealerships.
How does it work in reality? How do you make it last long?
http://www.edmunds.com/advice/buying/articles/42962/article....
According to this article, there are two kinds of dealerships -- high-pressure and low-pressure -- and the reporter spends some time working at each. The high-pressure Japanese dealership had an elaborate buying process with many additional costs, delays, and psychological tricks to greatly inflate the final price. "Let me talk with my manager" is used as a weapon.
But online research is a good idea. Some lines from the article:
"Three hundred below invoice," he smugly answered.
I asked how he did it. He said he checked prices on the Internet. He then called the fleet manager and made the deal over the phone.
I had a schizophrenic reaction to this. Part of me admired the fact that he had outfoxed the dealer. But the car salesman side of me was angry that I never "got a shot at him." It seemed like just a matter of time before people who, in the past, walked onto our car lot, would be on the Internet making deals.
if you do the right thing, e.g., get up and walk out, they will let you do it. then when you get to the parking lot, they'll run you down and try to convince you to start the process again.
it's really, really nuts.
As soon as financing or insurance come into the game, it gets really ridiculous.
I was going to a dental school for treatment which meant that I was being treated by students under the supervision of dentists. They don't have a financial incentive to find cavities and everything is checked by two dentists.
It's possible that they have an academic incentive to find cavities (more practice for example) but at least two dentists have to agree with their assessment before they continue.
Unfortunately they don't accept insurance and my insurance company is kind of a pain when it comes to out-of-network dentists.
When I graduated and got dental insurance, I immediately googled for "laser dentistry" in my area (having heard about it from my girlfriend). I chose the dentist with the highest ratings (well, one of the only dentists with any ratings at all).
Interesting fact: in 5 years, I apparently accumulated 5 cavities, none of them very serious. I got all 5 filled in under an hour, with no anesthetic whatsoever. Then, when I went for my checkup 6 months later, I had 2 new cavities. (Btw, if anyone is wondering, there is a low-power laser that reflects off your tooth enamel based on tooth density to determine which teeth need attention, and then there is a different high-power laser that actually gets rid of the decay).
Being my usual skeptic self, I started wondering if dentists didn't embellish reality a bit (or even create cavities while they're in there... ok, even I'm not that cynical, but I'd be lying if I said the thought didn't occur). Then again, my dietary and health habits probably did change considerably that first year after graduation.
In the end, I trust this particular dentist for a couple reasons.
1. He readily explains every step of every procedure he's doing, including how the tools work and why they work, even edge cases in which they wouldn't work. And he does so with enjoyment, like it's pleasant for him to have a patient interested in what he does. This appeals to the engineer in me.
2. He has said things to me like, "Well let's wait and see on that tooth. There's no reason we need to do anything to it just yet, it doesn't seem to be getting any worse." Also, when doing the laser fillings, he's asked, "Do you want anesthetic?" I responded, "do you think I need it?" And his answer: "Well, we can start without it, and then do it if things get too painful. No reason to numb you up and mess up your day if not necessary." Realizing that he'd get more money from me and my insurance if he used anesthetic, this alignment of interests was refreshing.
3. Given that every procedure I've had with him has been without anesthetic, I can say with certainty that he is extremely attentive to any pain I may have. He notices immediately if I wince at all, and makes adjustments accordingly, like turning down the power of the laser.
At the end of the day, I pay him for peace of mind, and he delivers.
What followed was a great experience: after 2 hours of patching things up, my pain was almost completely gone. After a few days of antibiotics, it was gone. The shot required to numb the area didn't hurt (it may have under normal circumstances, but ... "broken leg"). That single correction brought me back on schedule. I had a filling that was sensitive. He replaced it with a "new material", it was more sensitive, so he replaced it again with a different bonding (Neither I nor my insurance were charged) and that sensitivity went away. No cavity filled since then has been sensitive.
I've had a handful of cavities, and I return, reluctantly, but my loyalty lies more in the fact that I had a tangible, identifiable problem (excruciating pain, and later sensitivity) and he troubleshot it until it was fixed to my satisfaction. I wouldn't see another dentist simply because I believe this particular dentist to be predictable. I'll have a problem, he'll fix it. I, like other commentators, have a dentist who uses more than just X-Rays to diagnose cavities. At the moment, I have three spots on the X-Ray and DIAGNOdent that he has said he'd like to "wait on" because he wasn't sure. I had thought -- due to my past experience with tooth pain -- that "waiting on" something like that was asking for trouble, but now I'm wondering if I have a Dentist who understands the limitations of the technology he uses.
I was only there one time, and no harm was done, and no teeth were removed, but you can recognize many kids my from my city by them missing one or two teeth. I don't really know what to think of that, but it sounds like something straight out of a wicked story. I guess it is a wicked story.
Teeth are the most difficult part of your body to maintain, which makes it all the more awful considering how proportionally dependant you are on dentists compared to other experts you need regularly.
I was never afraid of dentists, because I was there to keep my teeth healthy (and as they always were, I didn't try nor fear a cavity and subsequent drill), but if I didn't have a dentist I loved dearly, I would probably shudder at the thought of them doing a sloppy job.
No. Cognitive dissonance is the pain caused by having two contradictory ideas at once.
Yes, the wording is technically incorrect, but the common usage of "cognitive dissonance" is generally about practical implications, like this.
I've tried his approach for a few years and so far no cavities. It comprises a hygiene regime designed to minimize the oral bacteria load by brushing immediate after eating and using salt water rinses.
It's the same way that the not-a-fatass plan isn't a secret, but most of this country (the US) is obese.
You can certainly google the dentist's name and read his account of his treatment by the dental association (this was back in the 70s if I remember right). I doubt he was making things up. I believe that when one of his patients came and tested with low oral bacterial count, the visit was free.
He himself clarifies that there is nothing magical about this system: "We aren't claiming to have come up with a revolutionary system ... we're not pushing any "miracle" drugs or anything like that, We are simply offering a commonsense approach to dental health, and the likes of that has never been available to the American people before. Oramedics is nothing more and nothing less than the simplest route to a disease-free oral ecology. And I think that anyone who is interested in regaining control over his or her life and body will surely want to know about it."
Why not wait till it's a bit more obvious? I don't mean wait till it's so bad you need a root canal, just till it's not a "maybe".
Cognitive dissonance? Cognitive cacophony.
My dentist doesn't take insurance and so he probably doesn't do this.
All my life I went to two dentists. Both were pretty good, and I had cavities pretty rarely.
Later, my parents had to switch insurance, so we went to another dentist with a much nicer office. He takes a quick look at my teeth and says, "Oh yeah, looks like about eight cavities. We should drill them etc etc"
My parents are shocked and take me back to our most used old dentist for a second opinion. He examines me closely with a pick and tells us the other guy is full of shit, and that behavior is really common in dentistry.