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Comment by donatj | Hacker News Reader

I went to a new dentist for a broken filling and they tried to tell me I had 14 cavities and set me down with a finance person to set up a payment plan for how I was going to pay for them over the next 5 years.

I went to a second dentist, they fixed the broken filling and said my teeth were otherwise fine. I have the paperwork to back this up.

I’d been seeing another dentist for a while and he suddenly wanted to crown 3 of my teeth. Again I got a second opinion, and again they were like “That’s probably not necessary”.

I think a lot of dentistry comes down to how much money they need that month. It certainly doesn’t feel very scientific.

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I went to the same dentist for years as a child. Brushed my teeth once a day, never had any issues at all. All of sudden, during a regular checkup, he told my parents (I was ~15 at the time) that I had 9 cavities and needed fillings. In the 20 years since, I have never had a single cavity. And what a shock, he sold his practice between that procedure and my next checkup. I fully believe he was just pumping up his revenue to increase the sale price, and my parents weren't health literate enough to get a second opinion, and I was too young to know that just because he has a white coat on doesn't mean he's a good person.

Dentists are in the sweet spot where they actually are very important and necessary (as opposed to chiropractors, who are universally charlatans and frauds), but they don't get quite the scrutiny and oversight that physicians are used to. And they make as much as some of the top tier physician specialties. PCPs, OBs, ER, etc. all make less than dentists by and large.

> as opposed to chiropractors, who are universally charlatans and frauds

I take it you've never thrown your back out and had an adjustment that fixed a lot of pain?

I take it you've never done much to strengthen your core and stretch your muscles properly?

A physical therapist can help you with that long-term back pain you got.

That a chiropractor can relieve pain doesn't mean that chiropractics in the "medical" sense isn't a fraud. Imaging that shown the entire concept of "subluxations" in the chiropractic sense are a myth.

I've gone to chiropractors for manipulations. Some even were able to bill my insurance (yet surprisingly the cash price was the same as my insurance copay, imagine that). But I treat it the same as getting a massage. It feels good, and I might feel better after, but it's absolutely not any sort of medical science.

What do you mean by "subluxations" being a myth? Most of my back issues come from subluxation of the T2 vertebra. As shown by x-rays and physically being able to feel that is is out of alignment with the rest of the spine.

Are you referring to those charts that say these are the random other symptoms you might have from alignment issues? Those definitely seem shady, and pseudoscience at best.

Edit: Oh, I see. Overloaded term. I was coming from the medical side, but it can be used differently in a Chiropractic sense. https://en.wikipedia.org/wiki/Chiropractic#Vertebral_subluxa...

Yes, I just meant the chiropractic side. They're absolutely real and can be a problem medically. Chiros sort of co-opted it.

Yeah, I'm not sure about this. After two car accidents one year apart my back was killing me. I went to a year for physio and nothing happened. Then a friend recommended this chiropractor and within 3 months I was fine. To be fair this chiropractor said alot of chiropractic was a bit fluffy, and I insisted we discuss the science behind it and stuff which he was totally literate about.

I'd go to another one again.

> I take it you've never thrown your back out and had an adjustment that fixed a lot of pain?

A _good_ chiropractor will only perform adjustments, but the foundations of Chiropractic "medicine" is pseudoscience that many still practice to this day. Wikipedia has a good summary on this: https://en.wikipedia.org/wiki/Chiropractic#Pseudoscience_ver...

But, in my opinion, if you're only going to a chiropractor for adjustments you'd be better off finding a Registered Massage Therapist or Physical Therapist (depending on your level of pain).

If you're reading this and haven't, please click the Wikipedia link. Scroll down to the photo labeled "A chiropractic manipulation of a horse."

I hope it makes you laugh as much as it did for me.

There's a million videos of pets and animals getting adjusted on youtube. Hard to take any of it as a serious science. Search "Goose chiropractics."

Equine chiropractors are pretty mainstream nowadays. The one I use is an excellent vet to start with who also does adjustments. There's wackos out there, but there's definitely some properly trained individuals who do a lot of good. I get my mare done every other year or so. Her back gets sore, it's super obvious when you're riding her, the chiro comes out, and she's so much more relaxed and moves more freely when I get on her the next day. A year or two later, she's sore again and we repeat.

Crap, even the old school Kansas cowboy I used to ride with uses them. When his ranch horses start acting sore, he gets a chiro out. The man can do pretty much anything else veterinary himself, and does, but calls in an equine chiro for his working animals.

In the past, I spent a lot of money on chiros basically "cracking" my back. I eventually taught my partner how to do it and she does it so much better than any chiro ever did.

One thing I will say after having seen ~10 chiros is that the ones who actually x-ray you are the only ones I would place any trust in.

The science presents that the only proven outcome of Chiropractic is sudden death.

Having spent many years dealing with chiropractors... There are two types of issue they handle. The first is sharp pain due to some, likely traumatic, event like whiplash or trying to pick something up that is too heavy or a sports injury. They can often fix those issues with limited treatment and a few exercises.

Then there is chronic pain due to some issue like disk breakdown or another illness. They can do little to nothing with these illnesses but they will not admit that. They will bill your insurance for all they can and eventually when insurance will not cover it anymore they will try to get you to pay out of pocket or tell you to kick rocks.

I wish chiropractors would be upfront about this but I've never talked to one that is willing to. I have spoken to several who I know socially who have said this is more or less true in their clinic. At least the part about being able to help some but being useless with chronic pain.

Are they fully charlatans and frauds? No. But they do take advantage of people who they cant help and promise something they cant give.

Yeah I think people are blinding themselves to the huge differences between chiropractors and just lumping all of what they do into one single bucket and tossing it out. In physical labor heavy areas they help a lot and 90% of their business comes from relieving pinched nerves, fixing dislocations, deep tissue massages, and physical therapy regimes. Nothing quacky about that, especially when it is hard to find a doctor these days who will put their knee into your back and pop your shoulder out and back into the proper place instead of prescribing narcotics and endless rest for weeks on end that is not feasible in those communities.

But on the other end of the scale, you also got ones who don't have that sort of business and are selling new-age crystal moon beam energy healing power and claiming anything and everything they can sell you will cure you of any and all ills which I think most people would consider irresponsible and dangerous.

One side argues for chiropractors because of what they do above on top of being super cheap and affordable for the average labor worker. The other side argues against it because they only see new-age crystal therapy in their areas while also being able to themselves afford better healthcare with a significantly less physically damaging workload.

Its complicated.

Technically speaking, if there's any decay in your teeth, that's a cavity. The deeper it is, the faster it'll get worse. When you want to get that filling though, is a judgement call that a lot of dentists make for you sadly. Is it best to go ahead and get those fillings now? Probably, as far as your dental health is concerned. Can it be delayed though and done later? Almost certainly. Just a bigger filling later. Or maybe a crown if it gets too far gone.

Also, how fast your decay progresses depends on a variety of factors. For some people, it won't be long before those questionable cavities become serious problems. For others, it can be many years if they decay much further at all even. I think it's largely genetic, but also depends on oral care, diet habits, etc.

So, no, I don't think most dentists are just seeing dollar signs and putting fillings onto teeth without cavities. Its not outright fraud or malpractice. But some dentists are sympathetic to your financial situation while others think dental health should be a priority above everything, no matter the cost.

So it's a mix I think, between dentists' values/philosophies about dental care, and the lack of science about how fast tooth decay can vary from person to person (and an inability to measure that).

It's not that cut and dry. Just because you have a small carie doesn't mean it's only going to get worse. That's the reason for fluoride in our water, in our toothpaste and in the wax the dentists applies at the end of your cleaning (that for some reason, insurance never wants to pay for).

Fluoride treatments and good dental hygiene can reverse carries. Carries should only be treated if they're large, or if they're still growing after discovery and alerting the patient.

And did you know dental plaque and tartar are actually protecting your teeth? And just because vanity we want to get it removed?

https://pubmed.ncbi.nlm.nih.gov/17016887/

In vitro study shows that plaque protects against externally-applied acid. Ok. Now what about the acid produced by the bacteria hiding behind the plaque?

Just because dental caries show up with plaque and tartar in no way means that plaque and tartar are causing the caries. These are the mechanism our body uses to protect our teeth from unbalanced oral bacteria. Just like the microbiome of the gut, we have one in our mouth. Removing plaque and tartar does not stop caries.

Caries are initiated by direct demineralization of the enamel of teeth due to lactic acid and other organic acids which accumulate in dental plaque. What is tartar?

Heavy staining and calculus deposits exhibited on the lingual surface of the mandibular anterior teeth, along the gumline

Tartar is a form of hardened dental plaque. It is caused by precipitation of minerals from saliva and gingival crevicular fluid in plaque on the teeth. This process of precipitation kills the bacterial cells within dental plaque.

Just because having plaque on your teeth will block acids doesn't mean it's actually a good idea not to clean your teeth.

I guess if you could show a study showing that leaving plaque/tartar on teeth leads to better health outcomes I might be interested.

If you leave the plaque and tartar on the teeth without fixing the fundamental problem (immune health) then there of course will not be better health outcomes.

Caries are a sign of an immune disorder or imbalance. As long as dentists only scrape peoples teeth and do not integrate their health into their practice you will keep having plaques and tartar to be remove as your body fight this battle.

https://www.lupus.org/news/people-with-lupus-exhibit-increas...

>Caries are a sign of an immune disorder or imbalance

Or just terrible habits like drinking liters of soda everyday. Besides the diabetes, the mix of sugar and acid is terrible for dental health, and contrary to the myth, brushing your teeth will not save them, at all, if one persists in terrible habits.

Sugar does not directly cause oral microbiome imbalance. Lipids do.

https://www.dentaleconomics.com/science-tech/oral-medicine-a...

The reason it's a good idea to clean your teeth is because if you don't they'll stink and become discolored. It's not because it keeps them healthy, because cleaning your teeth strips some protection from bacteria and acids away from them while deepening the pockets around them, creating a nice place for disease to live.

The idea that intensely cleaning your teeth (and keeping them white) is healthy is an intuitive leap that marketers take advantage of, just like the bad intuition that makes people clean their faces intensely to get rid of skin problems. The reality is more complicated. Clean, pure, healthy, white.

Fossils have better teeth than we do, but we have prettier, less fragrant teeth.

>Fossils have better teeth than we do, but we have prettier, less fragrant teeth.

That's because those fossils had way less access to sugar, which is the main reason we need so much more dental hygiene nowadays.

You all think sugar causes tooth decay, no, sorry. It's lipids. Not all bacteria use glucose, most use fatty acids for energy.

https://www.dentaleconomics.com/science-tech/oral-medicine-a...

It is more probably that the sugar throws off lipid metabolic and that changes the oral microbiome.

> Is it best to go ahead and get those fillings now? Probably, as far as your dental health is concerned.

Modern science says no, you should apply topical fluoride for most early cavities; and if the teeth use a modern pronamel (cough stuck behind USDA approval) should be able to recover quickly.

Could you add more regarding pronamel, so I can begin my negotiations with The Algorithm?

I think the poster might be referring to "Sensodyne Repair & Protect with NovaMin"

Previous mention: https://news.ycombinator.com/item?id=26644350

> Is it best to go ahead and get those fillings now? Probably, as far as your dental health is concerned.

This is mostly untrue. Fillings don't last forever, so prematurely filling cavities "starts the clock" on the longevity of the filling. When the dentist is replacing a broken filling, the dentist has to remove more of the tooth. Eventually you will need a root canal and/or crown. So for maximizing your health, the dentist still has to make a judgment call on how early or late to fill.

I say mostly because mercury amalgam fillings do seem like they can last effectively forever (20+ years), but they have fallen out of favor.

In our eastern european backwater and largely primitive country (Slovakia), greed has its prime. New dentist offices sprang up recently all over the place from where I come from. They took relatively big loans, and as greed is bottomless, want to pay them as quickly as possible to move to other investments.

I had similar experience as others - one guy wanted to set series of visits (4 hours each) to remove all older fillings. He was doing a fine work otherwise (replacing urgently one that started breaking apart). The detail being, he didn't do an X-ray to check if older fillings actually needed replacement (the idea is, your teeth can handle only few filling replacements depending on situation, so definitely don't fix things that aren't broken).

After that (and few months), went to another dentist who first did full x-ray, found that one filling needed replacement and the rest were fine and I ended up paying 5% of the price of first one. Good dentists are worth gold (same as many other professions for that matter) - if you find a skilled professional who is not ripping you off, you stay there till you die. This quality mix is unfortunately not easy to find.

Wife is a dentist. There certainly are practices where treatments are recommended as a function of money and cashflow (laser treatment and other "optional" treatments are a great example of this). However, crown / cavity recommendations are largely dependent on how aggressive that particular dentist's philosophy is. E.g. my wife only goes to her father for treatment because he focuses on saving teeth whenever possible.

Unlikely that a dentist would ever recommend filling cavities if they didn't believe it was necessary – they're not very profitable for practices. Crowns are sometimes recommended when a filling will suffice, but that's usually because crowns last ~10 years and fillings only delay the inevitable crown for a few years.

This is why I like going to dental schools faculty or student practices. They are all about saving the teeth if it can be saved and will need to see sufficient evidence in the imaging before moving forward with just about anything. Things seem to take longer and involve more appointments (e.g. i have to schedule a separate appointment with dept of radiology vs the private practice dentist walking me to the next room with the xray), but it seems like every decision involves multiple dental professors looking at my imagery or feeling up my teeth or gums before anything is done, which definitely boosts my confidence. I like having a committee and hearing them discuss the evidence in this war room setting when I'm laying there on the chair mouth open

I've looked into this myself and one negative is that students still have some pressure to overtreat because students have graduation requirements (e.g. must do a certain number of fillings, crowns, etc.). Granted, having to run everything by a supervisor will eliminate the egregious cases.

They can't overtreat due to the nature of it with literally all work needing a professor looking at the mouth or the work in progress and validating. If anything they need too much evidence to go forward and will want to see things like a CT to validate something in a traditional xray. When they want to do a certain amount of required things, they screen the local community for cavities and turn up plenty, including mine when I went and they were sure to point out the cavity to me on the imagery and go over my options and relative risks. Most of the times they are overburdened with demand of patients since this is about the only place where low income people can afford dental care so I expect they see plenty of examples to study. Oddly though my student told me he hoards extracted teeth to study and practice with.

There are a lot of decisions in dentistry that are subjective. There are a ton of borderline cases of cavities where you ask 5 dentists what they think, and 2 say to treat and 3 say to wait and see. This is what I'm talking about where dental schools will probably lean towards treating.

I had a similar experience with a dentist.

All my previous experiences I had minimal issues, and then suddenly at a different dentist I needed several fillings and needed to drill a good tooth to "fix a cavity" in-between my teeth.

I didn't get any of that done.

My next visit at a different dentist a couple years later and I had a single tooth that needed a filling.

When something feels off, it's always good to get a second opinion.

The thing seems to be more interesting, here I talked to the university dentist, and it seems there a like 4 stages of cavity, and you only start treatment at stage 4. But it seems not 100% clearcut when stage 4 is reached.

Unnecessary medical procedures are extremely immoral, do you mind sharing what country/practice this was in?

United States. Here’s my yelp review of the first place.

https://www.yelp.com/biz/shamblott-family-dentistry-hopkins?...

Not OP, but there's been a lot of this in the US.

https://www.pbs.org/wgbh/frontline/article/patients-pressure...

> Former employees say Aspen Dental trained them in high-pressure sales. Corporate management scrutinizes the production of dentists and staff daily. And internal documents show that dentists get paid bonuses as key production targets are met.

https://www.elpasotimes.com/story/news/health/2018/01/10/koo...

> "Especially when that fraud involves performing unnecessary procedures on kids —here, unnecessary baby root canals and tooth extractions, among other procedures —we will not hesitate to use every tool at our disposal to punish those who break the law," Bash said.

> The accusations against Kool Smiles included prohibiting parents from being present during root canals "to keep hidden the child's suffering" and retaliation against "unproductive" dentists, according to a federal complaint filed in San Antonio in 2013.

> 2013.

So they never got punished?

"Kool Smiles to pay $23.9 million" sounds like they're being punished?

They typically settle and sometimes pay a fine.

https://ag.ny.gov/press-release/2015/ag-schneiderman-announc...

I suspect they still make more profit than they lose in fines.

Having an unexpected cost and thereby not making a profit isn't actually a punishment - it makes the risk calculus a tame "I probably won't get caught", while the expected value remains positive. I realize I'm criticizing our entire enforcement philosophy for white collar crime here. But still, unless there are actual routine-disrupting punishments like jail time for violating basic professional responsibilities, we would expect unethical behavior to just continue increasing.

And this goes double for setups to make such violations "nobody's fault" like the creation of perverse incentive structures. In the context of blue collar crime, that's called a "conspiracy".

My wife went to Aspen recently (we didn't know better). They told her that she had periodontal disease and needed an expensive procedure. She was shuffled into a "financing" room before even completing her checkup. While waiting, she Googled Aspen and figured out that this happens to oodles of people, declined, and went to another dentist. No problems detected.

In addition to being a scam organization, we got to see the group of people in the waiting rooms at Aspen vs our current dentist. As you can imagine, the folks waiting in the Aspen waiting room are observably less wealthy and are statistically going to be less able to defend themselves against medical scams.

Evil organization.

It is unbelievable how much my faith in the necessity of dental procedures has risen after I started going to see a dentist that was my friend first, and my dentist only later (after I got tired of constantly wondering if the others actually had my best interests at heart).

I never doubted the dentist I had during my youth, and as far as I know he’s actually just really good at his job, so it was kind of a shock to find that so many of them are just winging it.

This was my experience as well. I went to the same dentist office for years with no issues. He sold the practice so we went to the new guy...every single time we went in there was a cavity that needed to be filled.

Went to a new dentist and everything is fine again.

One of my good co-workers is daughter of a dentist from the UK. the practices there are much different. We have had him analyze xrays and scans, he says its fine the people here just want/need your money!

My dentist was arrested in the 80's. He gave me three unneeded root canals. He was sniffing laughing gas. Good times....

If you are in need of cavities repaired I suggest getting in touch with your local dental school. Once a year there will be a practical where students have to repair caveties on a patient, so they will often offer free cavity screening + repair to the public for these exams. When I went to one, they discovered a few very small ones that looked like they could get bad in the future and opted to just do them right then. Dental schools outside of this are probably the cheapest way to have competent dental work done especially if you are uninsured (payment plans will be very permissive too)

> I think a lot of dentistry comes down to how much money they need that month.

I notice that even with my NHS dentist and just in how long he recommends leaving it until next time.

When I went back after 18 months (on a recommendation of 12-18) I got a cursory checkup, probably the most glowing 'all fine' I've ever had, a routine X-ray (i.e. that wouldn't be due again for a while) and then he asked to see me in six. I double-took and confirmed, so booked in for six months.

(Then we had a pandemic and it was more than two years before I could get a non-emergent appointment. That went fine too.)

My dentist is very busy. That often means that I have to wait a couple of months before I can get an appointment, if I'm not in active pain. That is of course sometimes annoying. The flip side of that is I'm quite confident that she won't suggest anything that isn't necessary since she already have a full schedule.

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