Hacker News Reader

Comment by dentalthrowaway | Hacker News Reader

Throwaway because I run a large dental software company.

Dentistry is practiced as a business focused on maximizing revenue. Dentists are routinely coached to deploy sales tactics to increase their treatment acceptance beyond what is needed. If you walk into a dental office, you need to protect yourself from being abused. A second opinion unfortunately puts you in the same position, but now with a new dentist who will play into the narrative of only needing to monitor your condition for a while.

The business of dentistry is unfortunately antithetical to conservative treatment, which is almost always in the interest of the patient, because it results in significantly lower patient lifetime value.

View on HN

I've told this story here before, but I grew up with very health-illiterate parents, who were very "old school" in the sense that if anyone in a white coat said something, it was gospel. Doctor, dentist, nurse, whatever (curiously they had and still have extremely negative opinions of medical paraprofessionals like PAs and NPs).

Anyway, I was around 15 or 16 and had always had perfect dental checkups. One day I had another routine checkup, but now suddenly I had to get nine fillings. I asked my parents to get a second opinion, but they refused and I got the fillings. In a move that would surprise absolutely nobody, that dentist sold the practice a few months later. I'm 100% confident that he was just goosing his revenue to increase the sales price, or make it a more attractive acquisition based on the revenue trend. That was around 20 years ago and I haven't had a single other dental issue beyond getting my wisdom teeth removed a few years later.

I think dental care is super important, but dentists are concerned primarily with maximizing their revenue in a way that would get most physicians' licenses revoked.

Interesting. A similar thing happened to me. After a lifetime of zero cavities, the dentist I'd seen a few times for cleanings announces that my luck has run out -- I've got several cavities. I declined any work, but I was concerned. Shortly after that I ended up moving to a different state and it was about year before I got back in to a new dentist. I was dreading it since I figured he'd tell me I've got cavities. Nope -- said everything looks great, see you in 6 months!

Worse happened to me. I had no cavities until the age of 36. Then I apparently got two. New dentist. I went for a second opinion and a second new dentist confirmed it, but who knows. I got the fillings. Within six weeks, one of the teeth broke in half around the filling and the guy was trying to give me an emergency root canal. I ended up having to have it pulled. The other one broke in half a few months later, another emergency surgery. That time, I went in and I'm pretty sure he worked on me drunk.

I haven't tried to sue the guy, but I think seriously about firebombing his office every time I drive by it.

A few years ago, a friend of my cousin became a licensed dentist here in Sweden. My cousin had to remove a tooth and his friend gave him, I assume, a lower price because they're friends...

He removed a tooth alright, but the wrong one (on the wrong side). And apparently my cousin just assumed he worked on fixing something else, realising the mistake way too late.

I asked my cousin if he considered suing but he didn't want to do that because they're friends...

Weird situation.

Reminds me of people getting "THIS LEG" tattooed on the leg to be removed, perhaps something similar with a stick on tooth decoration could be worth it.

I used to live in Spain, and I remember being shocked when my doctor told me how common it was for people to have the wrong leg or kidney removed there. She was originally American, and implied there was a strong inverse correlation between the cap on malpractice damages and the number of incorrect organs/appendages detached. Honestly, although the American medical system is the pits, it gave me a better opinion of American tort law and made me believe that some of the seemingly superficial lawsuits in this country serve a better purpose of keeping the otherwise wild-west medical system in check.

[edit] just as a side note, I've noticed a strong trend here among people who also never "had a cavity" in another country until they were in the US

There was some pretty significant pressure against having doctors use checklists (like pilots have) - but it has also decreased errors significantly (both in aviation and in the medical field).

They also act as a form of documentation; I highly recommend checklists whenever I can.

It almost seems like tattooing "NOT THIS LEG" would be a safer move.

There must be options in between suing him and firebombing his office. Seriously, think about folks coming in after you. Try to at least file a complaint, or give a bad review some place.

Now I'm grateful for my parents' choice of dentist. She worked out of a small office attached to the back of her home, and had family members as office staff. This is in the 90's in a very posh suburb of a major city, not some backwater a long time ago. Anyways, that dentist always had unique advice, she told me that if I were going to only do either brushing or flossing, that I should do the flossing and skip the brushing. Doing both is better, but she observed that many people skip flossing too much. She also said that toothpaste was largely superficial, and good brushing without toothpaste was just as good. She also would spend lots of time literally demonstrating good brushing technique and explaining why to do it that way. I also have some slightly crooked teeth, she said to push them with my tongue instead of getting braces. When I grew up, before going to college, she advised me that I don't really need to see a dentist regularly as an adult, and my teeth will be alright as long as I continue brushing and flossing. Cool somewhat hippy dentist was right on all accounts, and I've had good dental health ever since. Another anecdote: she would trade dental services for my dad fixing her various dental machines and equipment. Not sure how that arrangement came about, my dad wasn't really qualified or anything, he was just pretty handy and usually managed to fix things more than break them. And it wasn't disguised charity or anything, we had no issues paying. Pretty cool dentist.

I've heard the "flossing more important than brushing" from a number of sources, and it makes sense; it can be a pain but it's literally getting at areas that your lips and tongue can't.

> curiously they had and still have extremely negative opinions of medical paraprofessionals like PAs and NPs

This isn't entirely unfounded. There are real concerns over replacing MDs with mid-levels with much less training. The AMA is significantly to blame for the switch, but as a general rule I won't see PA/NPs for anything beyond prescription refills or something like that.

But that routine care is a good case for PAs/NPs. Pulling blood once and year and refilling my inhaler doesn’t require any speciality knowledge that only an MD would have. Most people shouldn’t have any reason to avoid one for their annual check or treating a run-of-the-mill illness.

Even that is arguable; I'd rather see an MD for an annual physical. It seems like a routine thing to people not in the medical field, but there are a ton of little things that are checked and could be caught early. I'd rather have an actual doctor performing it.

A few years ago I went for an initial screening to 3 different dentists and was shocked by the gap in suggested treatments. One wanted to do major work on like 11-12 teeth, another just fillings on 2. It made me lose all trust in American dentistry and I ended up going to get work done at a dental school instead because I knew it would be supervised by professors who are not optimizing for their bottom line.

I remember a Swedish consumer advocacy show on public TV (Plus with Sverker Olofsson for all the Swedes out there) did this test some time in the early 00's, sending the same person to like 10 different dentists, including also public health care ones that don't have a profit motive, and they all had different results.

Similar story.

When I moved to the States (Oregon) for a few years, I had to hunt for a number of services, with dentistry being one of them. I worked for a pretty large SaaS private (at the time) company, so the perks were plentiful, but most importantly, private insurance was up there in terms of quality.

Now, I'm originally from Canada, and without getting into the differences in healthcare between the two countries, but the amount of discrepancies I also received, let alone front-desk saying "oh my goodness, your insurance is incredibly good!", usually always resulted in the dentist informing me that I have 12 cavities.

The sad thing was in shopping around, and going to a number of different places to try them out, all ranged between 12 and 6 cavities, some even suggesting major dental work (2 crowns) required. I even went to 'work colleagues' recommended ones. All gave shocking details about my teeth.

Depressed, and annoyed, I went back to Canada, saw my dentist (and got a second opinion from a 3rd-party as an A/B test), and had 0 cavities to report. The second opinion stated I also had 0 (with maybe 1 on the way, and if I wanted, could opt to have it addressed now, but not the end of the world).

In the end it was cheaper (in almost every way, sadly) to see the Dentist on trips back to Canada, instead of opting for what would effectively have been the decimation of my teeth in the States.

> I'm originally from Canada, and without getting into the differences in healthcare between the two countries

I mean, on paper, there isn’t much of a difference between the two countries when it comes to dentistry.

>Depressed, and annoyed, I went back to Canada

Dentistry is private in Canada, the same as it is in the US. Coverage is via private plans, and dentists will goose insurance charges just the same.

This. I brought my kid to check for his open-bite problem, seen 6 different orthodontists and oral surgeons, everyone has a different opinion: from removing 7 teeth then do a jaw surgery(a 70K expense) to using some rubber bands to pull down the front teeth and observe what happens next($4000), each one has a different opinion.

All dentists running practice are suggesting way more expensive approaches, the last and cheapest one is actually from a dentistry university, where the professor seems more interested in studying the case instead of doing a quick surgery with huge costs.

I have a very expensive surgery coming up on Wednesday next week. My original dentist didn't even see anything wrong with the tooth. New dentist saw a deep canal but did a deep cleaning (f-ing painful!), and told me to wait a few months to see if it heals. I insisted on seeing a periodontist sooner. Tooth must come out. Sought 2nd opinion - she is convicned two teeth must come out. Then changed her mind. Now telling me bone graft material in the US is superior and I'd better get it done here than originally planned in a few months in Europe (thus saving a few thousand dollars and postponing some suffering so I can go on a vacation). Getting a third opinion the night before the surgery and literally don't know what I am going to do with it. What even the F.

Is it just me or do dentists rarely if ever suggest that their adult patients change their diet to avoid dental caries? They probably still tell children "don't eat candy", but since I reached adulthood I don't think a dentist ever told me suggested that the reason I needed so many cavities drilled was because I was feeding bacteria in my mouth.

If my experience is as ubiquitous as I suspect, there seems to be a perverse incentive among dentists to allow adults to ruin their own teeth. It's convenient because most people know extremely little about dental health beyond brushing and flossing. A minor carie on the enamel doesn't necessarily progress further than surface damage, and in some cases can even be reversed. Instead of saving the patient time and money by waiting for further progression of a carie, many dentists see the tiniest surface divot as an opportunity to drill n' fill. A more appropriate response would be to suggest the patient eat an appropriate diet that doesn't feed carie-causing bacteria and to come back in 6 months to a year for a follow-up; if the carie is visibly worse, then now it's time to consider drilling.

In defense of dentists, I imagine so few adult patients are compliant with suggestions of lifestyle changes that they figure it's hopeless and they might as well be the ones to cash in on cavities rather than some other dentist. Everyone hates going to them and they know they can't win.

> If my experience is as ubiquitous as I suspect, there seems to be a perverse incentive among dentists to allow adults to ruin their own teeth.

If you read the thread, some dentists will perform needless work on healthy teeth to make money, so I doubt there’s an incentive to let adults ruin their teeth when you can just lie and say they need the work anyways.

A dentist once told me that it's worse for my teeth to sip a soda or a coffee slowly over several hours than to chug it all at once. I wonder if it was suggested because patients might actually do that, compared to not drinking soda or coffee at all.

(I might drink coffee slightly faster than I used to. I do not drink soda. I'm fine with stains but not unnecessary tooth decay.)

I've been told that drinking it via a straw is better on your teeth because the straw deposits it directly into your throat and doesn't swish it around your teeth, but in any case I suspect doctors and dentists have stopped telling people to change their diets because people just don't.

It would be hilarious if this turns out to be true. My wife eats slowly, has some dental problems. I eat extremely fast, have been criticized my whole childhood because of how fast I eat (and drink, but nowdays I drink only water).

I have zero dental problems.

Go to the dentist in France and they will warn you that without sealants you might get cavities. In the US most dentist don't even attempt to offer to adults the simple and cheap treatment that prevents 80% of cavaties.

I've gone to my current dentist for years and he's always extremely reluctant to even do fillings (last time he gave me a speech about how you can't replace what "God gave you" so you should just monitor it or so.) I think there are some dentists that legitimately care.

EDIT: Mine is actually in a very wealthy neighborhood and the lady who runs the practice (I think that's how it works?) has a reputation for buying state-of-the art tech.

Yeah; the ones who treat conservatively are gold. I'm still looking for one in my current location over ones who are aggressive in pushing additional treatments and things.

I've found that if you can get conversational with the hygienists outside of the office they usually know who is who.

But that can be a chicken-and-egg problem if you don't know any hygienists.

Basically you go to several dentists and chose the conservative one - it is not that hard. Yeah, most of them are in so so neighbouhoods and have outdated equipment, but you wanted to have less intervention in any case, right?

This. I come from a family of dentists and they are very hesitant to drill unless absolutely necessary. Their rationale as I understand it is that all fillings, crowns, bridges, etc fail eventually. That anytime you attach something to a tooth you add a failure point and potential for infection.

The problem is their businesses can’t compete with the ones that play the insurance game. Insurance reimbursement rates haven’t kept up with overhead and so conservative dentistry is losing marketshare to ones willing to push treatment. We know multiple dentists that have filed bankruptcy in the last couple years.

Keep in mind that many people are very reluctant to pay out of pocket for dentistry. Until insurance reimbursement rates favor conservative dentistry, nothing will change. More responsible dentists will lose their practices or turn to over treatment.

Maybe the HN crowd wisdom has some ideas on how we can improve this situation.

> Maybe the HN crowd wisdom has some ideas on how we can improve this situation.

HMO / Capitation dentistry is the obvious answer here, where your dentist gets paid X per patient per year, to focus on preventive instead of pushing unnecessary care.

It’s really hard to implement in the US though because people push for a lot of unnecessary stuff.

>It’s really hard to implement in the US though because people push for a lot of unnecessary stuff.

"Unnecessary" is in the eye of the beholder to a certain degree. Extracting a molar is pretty cheap. Root canals, implants, and crowns much less so. But, depending upon the circumstances, more expensive procedures may make sense.

Well sure, but in the universe where capitation rules the world, we have people clamoring for services that they say they need, but professionals refuse to provide.

And there are probably HN threads there explaining why we need to go to a fee-for-service model.

There’s a dentist near where I live in a wealthy neighborhood that I went to once and was great. Problem is, she’s expensive and doesn’t take insurance. She doesn’t need to push anything extra because everything is already priced where she needs it to be. Obviously that won’t work generally, but something to think about.

Same, we have had the same dentist for over 15 years and I now drive across town to visit him. Trustworthy and reluctant to do any care unless required. Still tells me I need to floss.

Ugh, yeah… it’s so frustrating that as a consumer you can’t tell for certain whether your teeth need to be drilled or not. I’d so much rather pay some bullshit dentist-needs-an-audi fee, rather than pay to needlessly destroy the structural integrity of my teeth so they can make a buck.

Incentives guide everything in medicine and it's really unfortunate. Even the best meaning doctors get pushed in that direction. See x patients a day for y minutes. X goes up 10% and y goes down 10% every year. My brother is in his residency and in one rotation was asked to see 35 patients a day at a clinic. Impossible to do anything but the most cursory work. Health advocacy is becoming a bigger thing in the United States and it will only continue. People need to remember that medicine is now a consumer good, with all of the pitfalls that entails.

> The business of dentistry is unfortunately antithetical to conservative treatment, which is almost always in the interest of the patient, because it results in significantly lower patient lifetime value.

Isn't this the case with other healthcare providers too, and not necessarily just dentists? For example, physicians will regularly make you wait at least 15 minutes—even in an empty office—so they can bill insurance for that extra time. They'll bill patients for "emotional/grief counseling" and lots of other unrelated charge codes as well. I've seen from firsthand experience how doctors will exploit patients and try to milk as much money as they can from them, rather than prioritizing their wellbeing and health.

Yes, principal-agent problems in healthcare are pervasive.

But while medical upcoding fleeces patients, providers often feel it victimless because the procedures are almost always diagnostic and confused providers believe them to be paid by some third party (insurance, the state, but surely not the patient).

Dentists, in contrast, don't just upcode diagnostics, they systematically over treat their patients.

> Dentistry is practiced as a business focused on maximizing revenue.

All medicine is practiced as a revenue maximizing business (or it would cease as an ongoing concern). It's easier to see this in dentistry since at some early point in the US the field/cartel opted out of many of the omnibus health payment plans that otherwise obfuscate value chains. Aside from the notable exception of tobacco cessation, disease prevention gets short shrift compared to intervention. This is slowly changing but has started from a tremendous deficit.

If this is really how you feel shouldn’t you get out of dentistry saas and find something you believe isn’t hurting society?

What's that unicorn that doesn't hurt society but still allows me to support my family?

What if I ask for a diagnosis and recommend course of treatment in writing, then?

Reply on news.ycombinator.com