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As I follow the debates about Obamacare: about rising health care costs, about insurance, about coverage and denials and debt, I've often found myself drawn into the side questions and stories about dental care.  I've followed these with interest, because of my experiences working the "front desk" at a small dental office several years back, and the privilege I had of working for an outstanding dentist who was truly dedicated to patient-based care.  I'm hoping my story can add a helpful perspective.  Please follow me past the fancy orange grille into our office for more...

Several years ago, I worked for a while at a small-town dental office.  There were two dental offices in town.  The other one, run by a father-son team, took everyone: they were on everyone's PPO list, they took all the emergencies, they ran orthodontia, periodontia, dentures, anything you needed in your mouth.  The word in town was that patient care was not exactly a guiding value at their office; they depended on volume instead.  Let's just say we got a lot of their botched cases and angry clients.

My dentist viewed things differently.  Above all, he was dedicated to the true care of his clients, as patients and as people.  He embraced a holistic approach to dentistry that knew the teeth were integral to the body.  He ran an interdisciplinary study group with a wide variety of dental and medical providers.  He specialized in the treatment of TMJ, refusing to accept that jaw surgery or a lifetime mouth guard was the only answer, and networking with a wide variety of medical peers to restore the clients to positive overall health.  His work was beautiful, but he was not a cosmetic dentist: form simply followed function.  As the teeth, bones, and muscles of a pained and twisted mouth relaxed and gained normal function, the client's smile and face transformed.  It was a true joy.

Primarily a family dentist, my dentist emphasized continual care and overall good health.  He worked hard to educate his patients.  Those who repeatedly refused to care for their teeth, expecting he could fix their neglect, he might gently refer to the other dentists' office.  For trusted patients, though, he'd drive over in the middle of the night if he needed to, to respond to a dental emergency.  He wanted to build relationships, not just fix teeth.

One important though often uncomfortable part of patient education, which fell mostly to me, was dental insurance and the cost of care.  Because he was patient-focused, my dentist refused to be controlled by any fee schedules associated with being "in-network", though he accepted assignment of benefits from any insurance company willing to pay.  Dental insurance rarely paid the full cost of dental care, not even routine cleanings; as a result, my dentist wanted every client to pay up front, and then later, receive (partial) reimbursement from their insurance.  As this would cause significant financial strain for many of our middle- and working-class patients, we made reasonable estimates of what their effective "co-pay" would be (the part we calculated the insurance wouldn't cover), and allowed them to pay just that portion up front.  This greatly reduced our accounts receivable from the previous years, when clients were not asked for their co-pay until after the insurance had paid (or not), the balance was due, and unsuspecting patients were furious their insurance hadn't paid as advertised.

Why didn't insurance fully cover even preventive care?  Was the dentist simply enriching himself?  Is this an example of why health care costs are skyrocketing?

Let me first explain a bit of the ongoing struggle we faced with the insurance companies as we sought to provide true patient-based care, and the Orwellian language the companies used.  Insurance companies make fee schedules, based on the codes for all the different dental procedures.  These schedules show what the companies accept as the base price for each procedure, and the percentage of that price they will pay.  Depending on the plan, some or, perhaps, many of the procedure codes may not be covered, regardless of what the plan language claims.  The insurance company calls their accepted prices "customary" or "necessary and reasonable".  What does that mean?  It doesn't mean that those prices are actually necessary or reasonable, or that other prices are unnecessary or unreasonable.  It certainly doesn't mean they are really customary, because each company has its own fee schedule, and they often vary widely.  (Some companies claim they survey dentists to get average fees, but despite knowing all the providers within a wide radius, we knew nobody who charged so little.)  No: it simply means that those prices are what the insurance company has determined are the minimum they can pay and still get away with convincing people to buy their insurance.  Even better, insurance companies almost never publish their fee schedules.  It's a guessing game.  We aggregated claim payment data and used it to forecast what each company might pay for current or future treatment.  However, there was no telling when a company might change their fee schedule, or even change what procedure codes they considered "eligible".  Furthermore, procedures lumped under the same code are not one-size-fits-all: a filling may be quick, or it may become incredibly complicated and time-consuming (say if a person generates a lot of saliva, or if his/her teeth are somewhat unusually shaped) - yet the insurance company insists there is only one "allowable" price to pay for each code.  Adhering to a fee schedule makes it very difficult to customize care to a patient's true needs.

Insurance companies also determined how often they would pay for certain procedures or codes.  This sounds reasonable, but in reality it had nothing to do with billing fraud or clients' health and everything to do with trying to avoid paying for needed care.  Most dental insurance plans cover two cleanings per twelve months, or one every six months.  If a patient has periodontal (gum) disease, or a very dry mouth caused by certain medications, most dentists will recommend cleanings on a 3- or 4-month cycle to prevent gumline cavities or infections.  When the insurance company refuses to pay, the company says these "extra cleanings" are not "necessary and reasonable" - even though they are preventing the patient from incurring gumline damage and costly follow-on treatment of fillings, root canals, implants, dentures, etc. (not to mention medical impacts such as heart disease).  For another example, many plans limit the number of office visits with the dentist him/herself.  While one or two visits a year may be sufficient for most patients (in conjunction with cleanings, typically), what if the patient gets a tooth knocked out in a basketball game, or starts clenching at night, or simply has a question about his/her oral health?  The insurance company says such consultations with the dentist are not "necessary and reasonable", but surely they are, from a patient care perspective: really the company is just saying it doesn't want to pay.  I spent a lot of time on the phone arguing with insurance companies.  I knew their policies backwards and forwards.  It was tiresome.

This plays out in more significant ways as well.  Sometimes a tooth doesn't need a buildup and a crown - a large and well-constructed filling is best for the patient's needs.  Many companies will say that, if that tooth has had a filling in the recent past (varies by company - one to five years was standard), it is "not medically necessary" to put a new filling on that tooth.  My dentist used to get very angry when the insurance companies would deny claims by stating the work was "not medically necessary".  My dentist called it practicing without a license.  I spent a lot of time explaining to patients that "not medically necessary" had no bearing on whether or not the procedure was truly medically necessary, and that such a statement of denial from their insurance company did not mean the dentist was lying to them in his recommended treatment plan.  It simply meant their insurance company didn't want to pay.  Dental insurance companies also play the same cap game as their medical counterparts.  Most dental insurance has an absurdly low annual cap.  Back then, a single root canal/buildup/crown could cost around $2000 all together.  Even with the insurance companies' lowball fee schedules and 50% payment on "major" dental work, a single crown and a couple of cleanings could max out a person's dental insurance for an entire year.  Need another filling?  Dental emergency?  It's on you.

Finally, I mentioned earlier that my dentist specialized in treatment of TMJ and other challenging myofascial pain.  The "standard" remedy for severe TMJ is jaw surgery, which can be invasive, harsh on the body, very expensive, and have a limited success rate.  However, most insurance companies considered surgery the "accepted" treatment.  TMJ falls in that horrific black hole between medical and dental insurance.  Most dental insurance considered it a medical issue no matter what, and nearly all medical insurance considered anything mouth-related, other than full-fledged jaw surgery, to be dental.  In addition to causing chronic pain, headaches, affected vision, and problems eating, speaking, or even sleeping, TMJ can ruin a person's teeth over time, with clenching, grinding, and an uneven bite wearing away the occlusal surfaces in ways the teeth weren't designed to protect against, or causing cracks and pain in the teeth leading to root canals and other major dental work.

My dentist coordinated with his network of specialists to develop a comprehensive, patient-based treatment plan for serious TMJ sufferers that could involve massage therapy, osteopathy, an orthotic (special bite guard designed to protect teeth and restore proper jaw function), orthodontia, periodontia, oral surgery, implants, and traditional restorative dentistry.  This sounds expensive, and sometimes it was - but it was far less expensive than jaw surgery, nowhere near as invasive, and nearly always successful - it was the best patient-based care in many circumstances.  It restored function and often created the "side effect" of a beautiful new smile.  However, the insurance companies refused to pay.  Dental said it was medical.  Medical said it was dental.  They both said there wasn't proper "evidence" for the procedures being performed - for example, if no decay was present on a tooth, insurance claimed there was no need to work on it - even if the work helped restore proper jaw position and function, obviating the need for surgery.  As a result, most of these comprehensive cases were paid in cash, sometimes with payment plans over time (the work often took years anyway, as after each step we waited for the body to adjust and recover).  One patient, a lawyer, went so far as to sue her medical insurance company for refusing to cover such alternate, less-costly treatment when they insisted again and again they would cover jaw surgery.  Their official denial letters kept telling her that the treatment she was receiving was "not medically necessary".

It is probably not surprising that a number of our patients dropped their dental insurance or spoke with their employers about obtaining a better plan.  We turned many of them into health advocates, inspired by their dentist's devotion to them and their overall health.

So why was our dental care so expensive?  And - was it really so expensive?  My dentist was a well-educated man, but by this point he had no college loans, his children were grown, and he owned the small property where his office was located.  Yet: he was what we would call now a progressive business owner, and he believed that good employees fostered better patient care.  First off, and perhaps most importantly, he ensured that all of us received a living wage - the dental assistants, the hygienist (who worked on commission), me, and even his wife, who would help out during busy periods.  Additionally, we received benefits including an HSA, paid vacation time that increased (up to several weeks total) based on years worked, and 401(k) matching funds.  We also received overtime when we deserved it, no questions asked.  In fact, often, if we wanted to work more, we could.  Because the dentist knew that better-trained and educated employees would provide better patient care, he paid us to attend his peers' study-group training and other professional development.  We also received a nearly inexhaustible amount of free dental care for ourselves and our families each year.  Remember - this was a very small town in a rural area.  If I had to guess now, I'd say there was a dwindling old guard of union Democrats, going quickly as the union plants closed; and a growing new guard of rural low-income Republicans.  Against these headwinds, my dentist treated us with respect, because he cared about us as people and wanted us to give the best care to his patients.

We ran a lot of the office on a shoestring - though spotless and fully functional, it had not been remodeled in years and years.  The dentist did not have the latest fancy tools.  He made his own models and orthotics. And he took time with the patients.  He was constantly busy, but he never rushed.  He was not afraid to ask me to reschedule appointments if he needed extra time with a patient to ensure they received the best, most appropriate care.  He met personally with just about everyone who came through the door, ensuring he fully understood their circumstances and often, by listening, coming to a much more accurate diagnosis. Many providers order a stack of tests.  My dentist simply listened.

The dentist was, of course, fully licensed.  He used a very talented local lab (actually a guy who had turned his garage into a lab) to prepare his crowns, bridges, and other dental work.  He carried insurance, and he paid all the requisite taxes for us, and for his business (no treating employees like "independent contractors").  He had taken a number of charity cases for years when he was younger and more idealistic; but the state dental plan (long gone) and other government dental coverage had completely dwindled away, and he found to his chagrin that it was far too expensive to continue working for free.  Still, he never turned down an established patient in need for lack of his/her ability to pay.  For example, he created beautiful, highly complicated partial dentures and bridges for an elderly client with an incredibly complex bite - and never charged her a dime more than she could afford.  The dentist always paid himself last: we employees were first, then business expenses, then a savings fund for future renovation of the office (note: he was not planning to take on debt and then pay interest on it, ultimately saving quite a bit of money), and finally himself.  If money ran short in a month, he took the hit.

Our clients were very loyal, though a few of them - often the most well-off - would conduct dental tourism to obtain work in Mexico, or other countries, at a fraction of our prices.  The work sometimes was very beautiful and durable.  Although their dental tourism challenged our continuity of care, we understood why some people chose to go elsewhere.  We knew there were solid reasons why comparable dental work is more expensive in the US, even when the dentist is being very fair - or perhaps, because the dentist is being fair.  The cost of living is higher here, by far.  Wages, benefits, insurance (liability, fire, etc), licensing, lab work, utilities, equipment, rent/property taxes, education (dental/hygienist/assistant training) - as well as roads, streetlights, running water, stable electricity.  Even something as simple as hiring someone to come clean the offices is a fraction of the cost in other countries as it was at our office - in small town America.  I'm sure in large US cities the costs are far greater.  And it is more expensive to provide patient-based care than to run people through a dental assembly line.

With such inequality in standard of living, the only way we could "compete" with medical tourism in developing countries would be to run our dental office like it were in a developing country.  But do we really want to deal with the effects of deregulation?  Lack of licensing?  Minimum wage and no benefits for the staff?  Should we tear up the streets and push half the city into slums?  Certainly, some big-government programs such as health care, infrastructure investments, and education credits will help reduce the cost of dental care at the provider level.  Getting as far away as we can from the for-profit insurance agencies would lower costs, too, as (for one) we wouldn't be constantly arguing with them to get them to pay up.  And equally, I am sure there are plenty of profit-driven or profit-influenced offices out there that are trying to beat the insurance companies at their own game by overbilling or fleecing clients.

But I believe that as we engage in these national discussions about managing health costs, we must remember first that dental care is integral to holistic medical care; second, that insurance companies are always out to make a profit; third, that the costs of doing business in a first-world country are unavoidably higher than in less-developed nations; and finally, that true patient-focused care takes time, and is never "one size fits all".  Above all, in our efforts to extend health care nationwide, we must avoid a race to the bottom that unfairly punishes our fellow Americans working in the "blue collar" jobs of the medical profession by slashing their wages and benefits as the low-hanging fruit of cost-cutting.

UPDATE: terjeanderson makes a great point in the comments about federally funded community health centers, many of which provide dental care.  Here is a link to find one near you: Find A Health Center

I have been out of the dental world for years, but another option for lower-cost dental care may include a dental school or hygienist/assistant training school nearby.  If you know of a nearby place of worship that sends mobile dental clinics to developing countries, it might be worth asking if they can host a local clinic as well.  If you know of other options, please add them in the comments.

It may seem silly to say, but diligent home care (regular flossing and brushing) can help keep the dentist away, too :)  For far less than the cost of a filling, your dentist can prescribe prescription-level fluoride toothpaste - which is a real lifesaver for those with dry mouths, perhaps due to medications.  Electric or ultrasonic toothbrushes may be very helpful for those with limited manual dexterity.  Placing sealants on kids' teeth (as chimene points out) can help prevent cavities for years to come.

Finally, ask questions at the dental office.  It can be uncomfortable to speak up, but make sure you understand what care you're getting, why, and what it will cost.  Ask to see the X-rays and have the dentist or a staff member explain the treatment they recommend.  Get a second opinion before committing to large treatment plans.  Ask the front desk to calculate your co-pay or obtain a predetermination from insurance.  If you have insurance, read the policy/plan language carefully and negotiate with the insurance provider if necessary - as the insured, you have a much stronger bargaining chip than the dental office does.  If things don't feel right after the treatment, tell your dentist - searing pain, for example, may be as simple as a new filling with a slightly new surface shape that threw off your bite, and often can be fixed very simply without additional cost.  If your dental office resists you being an informed patient/consumer, it may be time to look for other options - trust and good care go both directions.

Originally posted to Square Knot on Sat Nov 17, 2012 at 07:03 PM PST.

Also republished by Community Spotlight.

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Comment Preferences

  •  What this diary tells me is (6+ / 0-)

    what I already knew: Dental care is important and should be part of primary care.

    Also, people who work in Dentistry are judgmental. Which is easy to do when someone's paying the bill. I would have liked this diary better it hadn't come off with a prelude of judgmentalism followed by a litany of legalese.

  •  I am a consultant to health insurance companies (19+ / 0-)

    being developed throughout the country. I recently arranged a dinner with my dentist (and his dentist pals) to discuss ways in which dental plans might be more effectively structured. Thank you for your great insights. I intend to share your ideas with the plan designers.

    •  Thank you for your kind words. (7+ / 0-)

      I wish you the best with your project - there must be better ways to structure dental plans!

    •  Crowns and Implants are not "Cosmetic surgery" (7+ / 0-)

      I have had to pay for an implant and four crowns on two of my molars (three on one molar for bite-related problems) because the dental insurance my employer offers has defined all of these procedures as cosmetic surgery. Fortunately, I have a good job, so I can afford them out of pocket, but, it did mean shuffling other expenses to cover them.

      But, honestly, how could keeping from losing back molars be considered "cosmetic"? No one SEES those teeth, and they're vital for chewing any piece of food one eats.

      Also, I recently has gum graft surgery to restore lost tissue on my four lower front incisors. I paid the whole expense out of pocket as well, because the dental insurance would cover, at most, half. But, they solemnly offered to cover the full expense of dentures! Why not pay fully for a procedure that has kept me from losing teeth and requiring dentures in the first place?

      I kept hoping these issues would come up during the health care debate, so that some sanity would be imposed on dental insurance, but, it never did.

      Please pass this along to the health insurance companies: use a little common sense, here.  Paying for prevention is cheaper than paying for a cure.


  •  Dental care is unaffordable for most people (31+ / 0-)

    who work at lower/part time, or minimum wage jobs. Medicare-medicaid, if you qualify, doesn't offer much either. Trying to find a dentist who accepts it is a real challenge. I was told there were only 2 dentists who accepted it at all-and they had looong waiting lists. This is a couple of years ago, and in a major metropolitan area.

    Even if you are lucky enough to have a job that offers dental 'insurance', it is a sad joke. Unless you can translate ins co doublespeak, you can have a nasty surprise when you are presented with the bill.

    The people I know who don't see the dentist really need to go for medical-health reasons, not vanity.  The beautiful smile is becoming a status symbol. One more tool in the kit to tell the 'others' apart.

    I guess hoping there is a plan for everyone to get basic dental care is too much~. Next folks would be expecting to get refrigerators, microwaves, TV's cellphones..etc.

  •  Essential (25+ / 0-)

    Dental infections can cause death.

    Dental troubles cause pain and sometimes poor nutrition.

    People with bad teeth do not get hired for good jobs.

  •  Well golly, Rmoney was right! (18+ / 0-)

    Once Obama has bribed us with all that healthcare, Pell grant, and tax cut bling in exchange for our vote, us peons are gonna get all uppity and entitled-feelin' and start demanding coverage for dentistry. Can you imagine it? DENTISTRY! WTF Little People???

    Uninsured/underinsured people are currently forced to wait until they have a raging abscess, then go in agony to the ER to beg for painkillers and antibiotics -- and the likes of Rmoney can only sneer.


    by raincrow on Sat Nov 17, 2012 at 08:29:46 PM PST

  •  "Dental tourism" somehow doesn't sound right (5+ / 0-)

    to me, though I know some use that term.
    The people I know who have work done in Mexico ( myself included) , do it because it is the only alternative, not just to save a little.
     I appreciate that you did say some of the foreign work was well done ( though it can also be poorly done, certainly ,by some dentists).
    But I do think your diary is valuable, and a very important subject. Thanks for writing it. Tipped, recc'ed, and saved.

  •  we need dental care as part of health care (9+ / 0-)

    Over the last 30+ years, dentists often would mention my TMJ, but not one ever said anything about treatment or surgery.  I was hit in the side of my jaw with a ball bat when I was younger; could that have caused the TMJ?  I clenched my teeth at night sometimes and would wake up with headaches.  I had dental problems and lost all of my teeth and now have dentures that don't fit right.  I've lost over 40 lbs in the six months since I got the dentures.  I have lost my appetite and eating is difficult.  I'm on Medicare but have no dental care insurance.  I had to pay about $3000 this last spring to have my remaining teeth pulled and dentures made. I've been back a half dozen times for adjustments, but I still can't eat with the dentures.   I paid out many tens of thousands of dollars for dental care in my lifetime.  Fillings, root canals, crowns...many had to be replaced multiple times because of my TMJ.    Maybe I should have had jaw surgery back in 1974 after I got hit in the jaw...makes me wonder.

    •  dental health linked to heart health (5+ / 0-)
      Recommended by:
      kurt, radarlady, Square Knot, imagiste, glbTVET

      I do have heart disease also, along with dental issues.  Wonder why the U.S. has such high rates of heart disease...look also at our poor dental health.  Wonder if I should mention the TMJ to my doctor as a medical issue?  Would the TMJ be connected with my poor eating ability with the dentures?  

      •  Definitely worth asking (2+ / 0-)
        Recommended by:
        radarlady, BYw

        In our clinic, we saw that TMJ could be linked to a number of symptoms such as those that you described.  If a person's bite is off, they will continue to destroy teeth, crowns, bridges, dentures, etc., because their teeth are working in a way nature didn't intend.

        I hope you are able to find relief for your symptoms and hopefully determine the root cause.

  •  interesting diary. (10+ / 0-)

    I truly appreciate your perspective, but I'm not quite sure what's going to happen to the dental industry. People just can't afford dental care, and dental plans don't cut it (as you so eloquently described). I'm a 51 yr. old diabetic and my teeth hurt. The last time I was at the dentist was about 4 years ago. It's just too damned expensive.

    •  I agree with you! (8+ / 0-)

      I went to Mexico two years ago for dental work. I researched dental clinics for a year before I scheduled my appointment. I will probably make another appointment in a few months. My dentist was excellent and very reasonable. It helps that I live in New Mexico so I don't have to travel far for services. I won't pay American dental rates when I can have the job done for less by a competent foreign dentist! I don't have the money for expensive dental fees.

    •  Dental care intrinsically part of medical health. (1+ / 0-)
      Recommended by:

      So many dental issues are deeply linked to medical issues, as you point out - diabetics, cancer patients, pregnant women, anyone who takes a lot of medication - all of those people are at increased risk for dental problems.  And poor dental health often worsens one's overall health, as many have pointed out.

      I hope that our national conversation about healthcare helps put dental care and vision care on the table.  Big Pharma lobbied to include prescription drug benefits - we need to speak out for the other aspects of overall health as well.

      I hope you are able to obtain care - if you haven't checked already, there may be dental students or hygienists in training who could provide care at a lower cost, or perhaps a mobile clinic.

  •  Wonderful Diary! Dental care is a medical issue. (4+ / 0-)
    Recommended by:
    anafreeka, kurt, radarlady, Square Knot
  •  your old boss sounds like our current wonderful (3+ / 0-)
    Recommended by:
    radarlady, Square Knot, catwho

    dentist! he's just great, and we're happy (& happily able) to pay for his services without insurance.

    of course, we're lucky to have good teeth to begin with, and the parental units are old enough to have gotten a good foundation of care many years ago.

    We cannot sing the praises of PIT AND FISSURE SEALANT, new tech for kids' permanent teeth, since about 30 years ago; our 20yo has not a cavity in his head!

    Of course, as parents age, our old-style giant fillings, from the 50's & 60's are breaking our teeth, requiring crowns, but even without insurance, that's manageable at about one a year... and will soon have a full set, 8-).

    Will be really sad to leave "Dr Mac" when we finally move away for retirement; although that will probably coincide with his retirement anyway...

    "real" work : a job where you wash your hands BEFORE you use the bathroom...

    by chimene on Sun Nov 18, 2012 at 12:09:04 AM PST

    •  Sealant (1+ / 0-)
      Recommended by:

      This may have changed, but insurance used to deny coverage for sealant.  There was no unique code for it, and if billed as a "filling", they said there was no decay on the tooth and thus no need to put any substance on it.  Despite the fact that it prevented so many cavities from developing!

      How wonderful that you have found such a great dentist for all these years :)

    •  But just try getting any dentist (0+ / 0-)

      to admit that the fillings are breaking teeth.  It won't happen.

      It's always the patient's fault as far as they're concerned.

  •  i know some one whome will be helped by this diary (2+ / 0-)
    Recommended by:
    Square Knot, radarlady

    Mighyily. Recd. Tipped. Thanked

    "Are you bluish? You don't look bluish," attributed to poet Roger Joseph McGough, for the Beatles' Yellow Submarine (1968).

    by BlueStateRedhead on Sun Nov 18, 2012 at 05:18:46 AM PST

  •  National Insurance abroad (4+ / 0-)
    Recommended by:
    indres, Square Knot, radarlady, Mr Robert

    When I lived in England in the 60s and early 70s dental care was covered by the National Health program.  They dropped it a few years later for everyone but children under the age of 12.  Just couldn't keep up with the costs.

    We can certainly make a start toward better dental health care by eliminating sugar in the schools and in soft drinks.

    Is the government still paying subsidies to the sugar growers?

  •  What? (1+ / 0-)
    Recommended by:

    Isn't it normal to have Americans with mouthfuls of rotten teeth and the corresponding health issues?

    The Republican Party is Simply a Coalition of Greed and Hate

    by kerplunk on Sun Nov 18, 2012 at 08:14:58 AM PST

  •  federally funded community health centers (6+ / 0-)

    The availability and affordability of dental care is a huge issue across the country, especially in rural areas and poor urban neighbourhoods.

    One vital piece of making care available are the more than 1,400 FQHC (federally qualified health centers) across the country - a significant number of which have full dental clinics.

    The FQHC programme offers community-based care on a sliding scale basis, accepts all forms of insurance, and is an essential piece of the medical/dental safety net. For many people without insurance and with low incomes, it is the only practical way of accessing desperately needed dental care.

    As the patient of one of these clinics in a rural area, dealing with a series of complex procedures over an extended period to deal with severe problems that I couldn't afford to get treated anywhere else, I've been incredibly impressed with the professionalism, the patient-centered model, and the high standards of the clinic I've used. While I can't speak for all such clinics across the country, if my experience is representative, support for these clinics should be increased dramatically to help increase access to quality dental care for all.

    My friends, love is better than anger. Hope is better than fear. Optimism is better than despair. So let us be loving, hopeful and optimistic. And we’ll change the world - Jack Layton

    by terjeanderson on Sun Nov 18, 2012 at 08:19:36 AM PST

  •  timely diary (10+ / 0-)

    I just parted ways with my long term dentist - of 20 years - over a financial issue.  I liked my dentist very well, recommended her widely.  I live on a lean budget, as a single parent (widowed) with a son in college.  My teeth are in good health- I take care of them.  Dental care for me, has been twice yearly cleanings.  I'm in my 50's and have had one cavity in my life.

    My issue came with the dental team pressuring me to update XRays.  Mine were several years old.  I'm not big on XRays, but I trusted my dentist's judgment, and told her I'd update when I next came in.  

    So I had an appointment for a cleaning last week.  I nearly cancelled the cleaning for lack of money, but talked myself out of it, as I know self care means dental care.  So when I was sitting in the chair the hygenist tells me it's XRay time, I told her I was committed to updating XRays, but couldn't afford to have them done that day, and it would have to wait until Spring.  She consulted with my dentist, and came back to say if I couldn't afford both, I could have the XRay, and reschedule the cleaning.  !!!  I was being refused service.

    I sat there in stunned silence for  a moment digesting that.  No compromise, a hard line, XRays or get out of here.  I got up and left, and am now looking around for a new dentist.

    It hurts not  to be able to afford basic care.  It hurts that my dentist, someone with whom I had a good rapport, kicked me in the teeth for lack of insurance and extra money for procedures.  To have to leave without basic dental care, for which I was prepared to pay, was a sock in the mouth, literally.

    •  So sorry to hear that. (4+ / 0-)
      Recommended by:
      carolyn urban, radarlady, Catesby, Kevskos

      I hope you are able to find a new dentist who is more understanding of your situation and needs.

      X-rays are very valuable in helping dentists diagnose existing problems and locate areas of future concern, but there are other methods that can be used for patients who can't afford X-rays, or need to limit them (e.g. cancer survivors).  While X-rays can be critical for involved treatment such as orthodontia and implants, lack of recent X-rays should pose no barrier to basic dental care in most situations, as long as the patient understands that visual methods may not catch all the problems that X-rays can reveal.

    •  It's a liability issue for the dentist. (3+ / 0-)
      Recommended by:
      Square Knot, misslegalbeagle, Debby

      I can assure you that dentists get sued all the time for not diagnosing dental disease. Radiographs are a critical diagnostic tool. Too many dentists are getting sued for not taking radiographs and therefore missing hidden dental disease. Don't blame your former dentist.

  •  I love my dentist (4+ / 0-)

    I'm one of those affected by the stupid "yearly caps" - my maximum benefit each year is a measly $1000, which is enough work for a few fillings, or a root canal, or a crown.  I've paid a lot out of pocket, and I've had about $20,000 worth of work done over the years.

    To combat the steady decay of my teeth, my dentist put me on hyper fluoride toothpaste, and for the first time after that, I had no new cavities when I went for my cleaning and exam.   Since I switched to the 5X fluoride stuff,  I have not had any additional issues that were not already present develop.  It's amazing.... I wish I had known about prescription toothpaste ten years ago!

    Next January will be my very last crown.  After that, it'll be cleanings only.  

    I think my dentist is going to use me as a success story.

    The Cake is a lie. In Pie there is Truth. ~ Fordmandalay

    by catwho on Sun Nov 18, 2012 at 09:01:15 AM PST

  •  uhm (6+ / 0-)

    As i noted in a diary a couple of days ago I have also had some dentist issues, but I come at them from the point of view of a patient.

    In Canada the dentists have a set fee schedule, I believe negotiated with the insurance companies. While that makes billing easier it inhibits any competition based on price. Those without insurance get fleeced.

    Many dentists seem to see a mouth as a location to be mined for dollars. Although my dentist is technically excellent, I do not trust his referrals. He referred my daughter for braces, but when I asked the orthodontist if the braces were cosmetic or required, the answer was cosmetic (no thanks at x thousand dollars and no insurance. Next he said I needed a gum transplant. The next day, unsolicited I got a call from the gum transplant doctor ... another multi thousand dollar quote. I said no, and when I went to a dentist in Taiwan, the dentist said, although there was some receding, it was due to age and did not require treatment. Then there was the cost of a crown after a root canal - $1250 - again no thanks. I had it done in Taiwan for $320 ... by a dentist with more modern equipment, nicer staff, a far more beautiful office, and better technique. He also cleaned our teeth for $15 each .... far less than the $150 each charged in Canada ... and in Canada it is not the dentist doing the cleaning. There is no way anyone can justify $150 to clean teeth by a hygenist.

    With new technology now allowing dentists to clean teeth in 10 minutes with ultrasonic equipment maybe we will see widespread lower bills ... but don't bet on it ... no one wants to give up the golden goose. So they keep spending 1/2 an hour or more scaling so they can run up the bill.

    I am now on my fifth dentist since moving to our town ... and my basic conclusion is that dentists here are grossly overpaid and that we are overserviced. Faced with better dental habits they have less real work to do so they have gone in search of whatever will up their incomes ... whitening being i guess the latest fad. I know that their conventions are heavy on practice management ... another term for maximizing revenue per patient.

    In Canada the situation is different as there are programs for free/reduced cost dental care for low income residents, especially children ... but I would really like to see dentists be able to publish their fees and compete based on price. Our current system is stacked in favor of the dentists.

    Those who make peaceful revolution impossible will make violent revolution inevitable. - JFK

    by taonow on Sun Nov 18, 2012 at 09:04:49 AM PST

    •  Speaking for myself.... (3+ / 0-)
      Recommended by:
      Square Knot, pundit, AllisonInSeattle

      I would much rather have a dental hygienist do my cleanings. They have far more training and experience than most dentists when it comes to cleanings, especially in tricky cases where deep periodontal pockets are involved. way you'll ever get a thorough cleaning in ten minutes, even with an ultrasonic scaler. I will guarantee any cleaning that involves only an ultrasonic with no hand instrumentation is not completely thorough. Ultrasonics are great for overall debridement but there is no tactile sensitivity with them like there is hand instruments. There is absolutely no way any residual calculus under the gumline can be detected with an ultrasonic scaler.

    •  I was living in Boca Raton (3+ / 0-)
      Recommended by:
      blue drop, taonow, AllisonInSeattle

      and a friend of mine was a dental hygienist.  She was smart, and she only had the best intentions for me when she recommended her dentist, who she thought the world of.

      I was 30 at the time, and had perfect dental check-ups up until that point.

      In spite of a clean bill of health 4 months earlier, her dentist diagnosed 6 major fillings, plus said that I had gum issues and referred me to a periodontist friend.

      I got the fillings, and went to the periodontist who said I needed surgery on my whole mouth.  Otherwise I was about to lose all my teeth.  This came as a shock as 4 months before I was fine - but I was trusting.

      I didn't know that perio surgery shouldn't be done on all quarters of the mouth at once, and I came out in excruciating pain.  Which lasted for months.  I could barely eat.  I could not eat ice-cream again for years.  And, I stress, I had no noticeable problems before I went in - I thought this was good, preventative work.  For which I paid $10,000 out of pocket.

      I went back in for cleanings, which were unbearable, every few weeks, and three months later the perio said that my gums were as bad as when we started.

      So what was the whole point?  So I said fine, let me lose all my teeth.  Nothing was worth that kind of constant pain.

      Here I am 20 years later, on a new regimen of only getting treatment when I feel discomfort.  The two crowns the dentist put in, which long came unglued have stayed out and not caused any problems.  One tooth broke on a filling, and I had that fixed.

      But after 20 years of no further periodontal treatment in spite of the dire warnings, how many teeth have fallen out?  Precisely one - and one I was glad to lose because I have a small mouth to start off with.

      Unfortunately, there may be good dentists, but you guys have no standards that we can rely on.

      •  similar (1+ / 0-)
        Recommended by:

        Similar thing for my wife. Dentists here and her periodontist all said she needed this and that treatment and cleaning every 4 months ....

        So ... she goes back to Taiwan for a holiday and has 3 different dentists there check out her teeth because each one says "no problem". End result ... no problem.

        Dentists in North America are looking for problems maybe for extreme prevention or maybe to mine the mouth, but they rarely seem to consider it as a cost benefit analysis (as they people with no insurance as having no cost ... so bill baby bill).

        Those who make peaceful revolution impossible will make violent revolution inevitable. - JFK

        by taonow on Mon Nov 19, 2012 at 03:59:31 AM PST

        [ Parent ]

      •  Wow - sounds horrible. (1+ / 0-)
        Recommended by:

        I'm sorry you had such a negative experience with the dental providers, and I'm very glad that their predictions did not pan out and that you've been able to preserve good dental health.

        Even doing restorative (fillings) in multiple quadrants at once can really put a wrench in the mouth - it needs time to recover and adjust.

  •  Like Car Mechanics (4+ / 0-)

    who take advantage of the customer's lack of knowledge, too many dentists are "finding" cavities that do not exist.  It is pretty awful when they do this with a child.  they will absolutely be willing to put a child through the discomfort of unnecessary filling to pad their own pockets.

    About insurance, my son and I recently went to the same dentist and received the exact same service,check-up and cleaning.  My bill with no insurance: $150.  His bill with employer-based health insurance: $325 (all but $10.00 paid by the insurance company).

    •  yup (1+ / 0-)
      Recommended by:

      $150 for a check up and cleaning is outrageous (2 or 3 days wages for some people) when there is little skill or cost involved ... but $325 is plain insane.

      Those who make peaceful revolution impossible will make violent revolution inevitable. - JFK

      by taonow on Sun Nov 18, 2012 at 09:55:35 AM PST

      [ Parent ]

      •  Machines cost money, and (2+ / 0-)
        Recommended by:
        cloudbustingkid, pundit

        operating them properly requires skill and training.

        There are a number of steps that go on "behind the scenes" of a routine cleaning.  Well in advance, the front desk sends a reminder to the patient and often calls to confirm the appointment.  Before the visit, the patient's chart is pulled and their history reviewed.  This gives the dentist and hygienist a heads-up about any chronic issues, medications that could affect oral health or treatment, medical concerns, pending treatment, areas of concern such as "soft spots" that could later become decay, etc. If the patient is taking blood thinners, he/she is called ahead of time to adjust their dosage - otherwise they could bleed out in the dental chair.

        When they arrive for their appointment, the assistant takes new X-rays to see if any problems have developed since the last visit.  The hygienist or an assistant checks for periodontal disease by measuring how tightly the gums adhere to the teeth ("pockets") and looking for areas of recession.  They check for signs of oral cancer and evidence of clenching or grinding and use hand mirrors to check in, on, and around the patient's teeth, gums, tongue, and mouth.  Regardless of which method of cleaning they use, including ultrasonic, there may be some areas of buildup that require hand scaling.  The teeth are cleaned and polished.  The dentist then spends some time with the patient, listening to his/her concerns and reviewing relevant dental care issues.  If applicable, they may discuss treatment.  The hygienist or an assistant review oral care techniques and practices with the patient and often provide a new toothbrush, floss, etc.  If the patient has unique dental needs (e.g. braces), specific oral care techniques will be demonstrated.

        Finally, the front desk takes care of scheduling the patient for follow-up treatment or the next routine exam; and they handle all aspects of payment - not just collecting from the patient, but also billing the insurance, posting payments, dealing with credit cards, collecting on past due accounts, etc.  The patient's charts are updated (paper or electronic) with new X-rays, periodontal pocket readings, and clinical notes from the dentist and/or hygienist.  The room is cleaned for the next patient and the tools are sterilized.

        Alternatively, for those who do not want or cannot afford that level of care, a home care tool such as Sonicare or similar may be a preferred option.

  •  Agreement and Comments (2+ / 0-)
    Recommended by:
    Square Knot, radarlady

    1)My wife and I have a wonderful dentist who is costly but well worth the expense.

    2)He does not take any dental insurance. As such we have used either a flexible spending account, out-of-pocket, or a dental reimbursement insurance plan.

    3)Dental insurance typically caps the maximum annual benefit at $1500. That may cover 2 prophylactic visits/yr, and part of one root canal and crown, if you are lucky. Dental insurance is a marginal benefit for many of us. In addition, the $1500/yr cap has been in place for >10 years and clearly has not kept pace with either CPI or with "dental fee inflation"

    4)Most Americans spend more for and take better care of their automobile than their teeth.

    5)Our experience with a dental HMO in the past was terrible.

  •  Well, your dentist was cetainly a paragon (1+ / 0-)
    Recommended by:

    of virtue and your article very comprehensive, and well researched.  But your knowledge of what goes on in the dentist's office and about dental insurance seems to be greater than just someone who worked in a dentist's office for a while some years back.  Why did you write this article?
    Just for fun ?

    •  No ulterior motives! (1+ / 0-)
      Recommended by:

      Had just read some recent comments about dental care and wanted to provide my experience - particularly to point out why patient-centered care and properly compensated employees result in higher health care costs than at those facilities that put patients through "assembly line" treatment.

      Thanks for reading and commenting.

  •  Cleaning the teeth (8+ / 0-)

    There's three things that collect on your teeth. Food debris, plaque (or biofilm), and tartar (or calculus), a mineralized deposit. The only one a professional needs to remove is the tartar. The food debris and biofilm are back on your teeth real quick. The secret to life is to remove the food debris and biofilm at least twice daily, using toothpaste with fluoride. When does the fluoride work? When it's touching your teeth. You gotta get the fluoride out of the tube and onto your teeth, at least twice daily. There is nothing to be gained from rinsing all that topical fluoride out of your mouth after brushing. Spit, spit, spit. Don't rinse.

    As to sweets, it's not the sweet that gets you, it's the exposures. Unless it's a real sticky sweet, your saliva will clear it in about 20 minutes. Worst way to drink a sugary beverage? A sip every 20 minutes. Worst way to eat a candy bar? Take a bite every 20 minutes. So what's this biofilm? Bacteria, saliva, cellular debris. It's that fuzz that covers your teeth when you wake up. Don't brush your teeth, and it's like they're wearing a sweater. Food debris is not plaque. You can rinse out food debris, you cannot rinse out plaque.

    Big problem is the bacteria in the biofilm eat the same foods you eat. Then they secrete a waste product. So basically the germs are shitting on your teeth. The waste product is an acid, so there is acid in the fuzz on your teeth. This acid dissolves the minerals out of your teeth. Luckily, your teeth can remineralize, and they can remineralize damn well in the presence of fluoride. But the repeated demineralization/remineralization takes its toll, and eventually the matrix of the tooth breaks down and the tooth can no longer remineralize. Then you've got a cavity. Now you're in trouble, because this creates an area impossible to clean, the destruction is relentless, and will get thru the enamel into the dentin. Unlike the enamel, the dentin cannot remineralize, so eventually some dentist's phone will ring. Almost everything dentists do is preventable. Most of your teeth you've had since about age 13, a dozen are about six years older. They're just about the only thing in your body unable to heal. The best work by the best dentist will fail, if not kept clean. And nothing lasts forever.

  •  If he wants a job as a county dentist we need him (3+ / 0-)
    Recommended by:
    marykk, radarlady, Square Knot

    I lost my dental care. The county wants payment UPFRONT and we just don't have it. AND any vet who is not 100% service connected is NOT eligible and the V.A. does NOT care!

    “To care for him who shall have borne the battle, and for his widow, and his orphan” -Abraham Lincoln. V.A. motto adopted 1959.

    by glbTVET on Sun Nov 18, 2012 at 12:03:02 PM PST

  •  This is all very revealing (5+ / 0-)

    and the information is useful, no doubt; but you lost me at the description of your kind, wonderful dentist "gently" sending people elsewhere if they didn't visit him routinely and only came in for emergencies.

    There are people who cannot afford to visit a dentist except in emergencies, and sometimes not even then.

    It's pretty disconcerting to hear that the "good" dentists don't want to bother with those people.

    •  Ditto. (3+ / 0-)

      What arrogance.  I would love to be able to visit a dentist regularly.  Which utility should I not pay to enable me to do it?  

      It's no more than "let 'em eat cake."

      Dental care - like all health care - is a human right.  And I believe that it should be provided for by single payer health care, and reimbursed fairly, but not excessively.  

      Justice For Will Will spent his brief, courageous life fighting for the rights we all take for granted. Please share his story to support the fight!

      by KibbutzAmiad on Sun Nov 18, 2012 at 12:50:22 PM PST

      [ Parent ]

      •  I understand. (0+ / 0-)

        I am painting the picture of a real person and a real practice, warts and all.  In his younger years, my dentist had taken a number of emergencies from patients who did not take care of their mouths, did not live in the area, and did not want the best care for their mouths - only a temporary fix.

        From the "cold-hearted" view of managing his small business, my dentist decided these patients were not the ones he wanted to build his practice around.  He also did not feel right doing treatment that he felt was incomplete or inadequate because the patients demanded a quick/cheap solution, or sometimes refused any treatment other than pulling their teeth, which my dentist felt was very detrimental to their long-term overall health.  The other dentists (who were very close by - it was a small town) - were generally very glad to take the emergency cases.  If they did not, or if we had room in the schedule to treat them without bumping other patients, we did treat emergencies.  I'd say we probably treated about half the emergency calls we received, and a few of those patients did end up turning into long-term clients.

        Was it tough to refer people to other providers?  Was it tough to field calls from people who could not afford to pay anything for treatment and had no insurance?  You bet.  I hear you both, and I wish we could have cared for everyone regardless of circumstance, but I recognize that then the business would not have stayed running for very long.

        •  you say they didn't "Want" (2+ / 0-)
          Recommended by:
          AllisonInSeattle, Square Knot

          the best care for their mouths.  I seriously doubt that was true.  What is much more likely is this: they couldn't afford the "best care".  A big difference.

          As both a small business owner and a person with many dental problems, I understand the issue of money very well.  But dental care is a human right.  And it should be dealt with as such, even if it means nationalizing the "product."  Profit - when it stands in the way of millions getting essential care - is expendable.

          Justice For Will Will spent his brief, courageous life fighting for the rights we all take for granted. Please share his story to support the fight!

          by KibbutzAmiad on Mon Nov 19, 2012 at 05:31:44 AM PST

          [ Parent ]

          •  I agree that all aspects of health care (1+ / 0-)
            Recommended by:

            are best served when profit is taken out of the equation, and that financial concerns can have a huge impact on the level and frequency of professional dental care a patient requests.

            Single-payer health care (including dental, vision, etc.) is not perfect, but it could ensure that the practitioners and support staff receive living wages; that the overhead of the clinic is reliably covered; and that everyone can receive basic care, regardless of their income level.  The government could also offer education grants or loan forgiveness for those who commit to work in rural or underserved areas.

            I am all for getting profit out of health care!

  •  Willard Mitt ouRmoney may have had a pretty good (3+ / 0-)
    Recommended by:
    Square Knot, Debby, Trotskyrepublican

    idea last week when he snarkcastically suggested that the dems offer dental care as part of an appeal for new and continued voters.
    Sounds right to me!
    Thanks, Willard.
    Now you may return to obscurity. We will try to remember you and your contribution.

  •  I hope next life your dentist is poor with a (3+ / 0-)
    Recommended by:
    Catesby, Kevskos, AllisonInSeattle

    severe impacted tooth, and a dentist refuses to treat  him because he only comes in when there is a problem.

    He is exactly the problem with medical care in this country. Rich SOB angry cause people only show up when they are in pain, care costs more than insurance. I couldn't even read past a few paragraphs.

    How big is your personal carbon footprint?

    by ban nock on Sun Nov 18, 2012 at 04:43:49 PM PST

    •  I'm sorry the diary put you off. (1+ / 0-)
      Recommended by:

      My dentist had worked many years serving those who could not afford to pay, particularly children, back when his state had dental clinics and basic dental plans for the poor.  He worked very hard at patient care, but became frustrated when the patients did not care for their teeth regularly (including home care), even when their preventive and basic restorative treatment was entirely free to them.

      One of the big challenges in our town was educating patients of all income levels that it was a good thing to try and keep natural teeth as long as possible.  Almost none of the older people in town had their teeth, and most people expected that if a tooth went bad, they simply had it pulled, until they ended up with dentures in their 30s or 40s.  Meth was another big problem in the town, and it does a horrible number on teeth.

      I respect the decision my dentist made to focus on his own retirement and financial security after dedicating many years to providing dental care to those who couldn't afford it.

      Ultimately, I believe the answer is single-payer health care that incorporates all aspects of care, including dental, and ensures that everyone receives at least basic treatment regardless of ability to pay.

      •  And then there's people like me (1+ / 0-)
        Recommended by:

        who spent 10s of thousands of dollars on care, with regular check ups, and extensive home care, only to be told all of that was worthless and I was in imminent danger of losing ALL MY TEETH unless I forked over another $10K

        Except that I didn't, and still had all my teeth 20 years later.

  •  my dentist wanted to take digital photos (3+ / 0-)

    i said OK.  i thought he just wanted to show me close up images of some problem areas.  he didn't tell me he was going to charge $10.00 for each.  six images - $60.  he knew i was a cash customer so they 'discounted' the price.  i complained at the desk that i wasn't expecting any charge at all.  i was told, "well, we normally charge $20.00 each but we reduced it for you."

    i paid it but i never went back.  i haven't had a truthful, honest and  reasonable dentist in 12 years.

    I'm a blue drop in a red bucket.

    by blue drop on Sun Nov 18, 2012 at 09:37:45 PM PST

  •  here is a link to a PBS Frontline special (2+ / 0-)
    Recommended by:
    Square Knot, AllisonInSeattle

    i haven't had a chance to watch it, yet, but it sounds like it addresses the problem of dental care in America.

    Dollars and Dentists

    also, a New York Times article about emergency room treatment for preventable dental issues.

    Dental Insurance but No Dentists

    dentists are making the problem worse by not allowing an intermediate and less costly alternative, dental therapists, to enter the industry.

    I'm a blue drop in a red bucket.

    by blue drop on Sun Nov 18, 2012 at 09:53:54 PM PST

  •  I've got to find a new dentist. (3+ / 0-)

    I've been seeing one for 8 years and had lots of work done and have a gold standard dental insurance program.

    Recently he took his practice out of my dental network and didn't inform me (nor probably any of his patients) in advance.  I had to get a crown replaced that broke off. (apparently because he could have and should have made the initial post longer).

    Not only did he not offer to give me a break because of his mistake he charged me almost a hundred dollars more than I normally have paid out of pocket, with no advance warning.

    I've been generally satisfied with his work and he has a high volume office.  He and his assistants do push extra/unnecessary services and aesthetics that put me off because of the inherent conflict between healthcare and cosmetics. With his going off plan I've decided not to reward his greed by staying with him.

    •  Traditional patient-based care definitely (2+ / 0-)
      Recommended by:
      AllisonInSeattle, Oh Mary Oh

      has lower profit margins than cosmetic dentistry.  I can see how through greed or need (like repaying dental school bills), dentists feel constant pressure to expand their profit margins.  It's unfortunate when they choose to do so by trying to mislead or overcharge patients.

      I hope you are able to find a better dentist who is more committed to your care.

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