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“I Have To See A Specialist? Why Can’t You Do It?!”

Dentistry is a specialty of medicine. Within dentistry, there are subspecialties.  There are oral surgeons that only do surgery such as removing teeth and placing implants.  There are periodontists that focus on gum surgery and placing implants as well.  Then you have endodontists that are dentists that do root canals all day.  There are pediatric dentists that only treat kids.  And we all know what orthodontists do.  There are more dental specialists I haven’t even mentioned- all with advanced training and additional years of schooling.

If dentistry is so complicated that it warrants dental specialists, do you really think your general dentist can do it all?  Some patients do!  They get upset that their dentist can’t do everything “in house”.  Yes, going to another office is a pain.  You have to set up an appointment, fill out more paperwork, see a stranger for a procedure you probably don’t want to have done, and then come back to your general dentist.  Is it worth it?  Depends if you value your teeth or not.  Do you want good work and a good experience or do you want convenience?

When your dentist gives you a referral to see a specialist, s/he is saying, “I’m putting you in the best hands possible to handle this procedure.  Your health and well-being are more important to me than losing out on potential income.”  Is the specialist more expensive? Maybe. But dental insurance usually pays more when a specialist does the procedure.  You also have to ask yourself some questions.  Even though you might pay a little more, will the treatment last longer?  Will it be more convenient?  “My general dentist says he can do it but it will take 3 hours while the specialist can do it in 45 minutes.”  Does that have any value to you?  Have you ever had to hold your mouth open for 3 hours??

Here’s another thing to consider.  Not all specialists are created equal.  I’ve had patients that threw away my referral and found another specialist- usually at a cheaper cost.  Guess what?  The work had to be redone.  It was a nightmare to deal with.  Trust your dentist.  My favorite patients are the ones that ask, “Is this the person you would send your kids to?”  Yep, that’s them.  I assume you come to me because I’m the best at what I do.  I also send you to whomever I think is the best.  I don’t want problems coming back to fall in my lap and I’m sure you don’t either.

You probably don’t want to see a general dentist that claims to do everything that comes in the door.  Most general dentists I’ve met that claim to be good at everything I wouldn’t let near my mouth.  Some are truly dedicated and are masters in all aspects of dentistry.  They’ve taken countless hours of continuing education to master all aspects of dentistry.  These dentists are however very rare (more rare than current marketing suggests).

Most general dentists provide a nice mix of the most common procedures done at the highest level. When they know the specialist can do a better job handling your needs, they refer. Luckily, in my area we have great specialists that are committed to doing things right.   There isn’t much to be gained to try to do it all yourself (unless that BMW payment is due).  Luckily, I drive a VW that’s paid for.

Dentist awards and other marketing gimmicks

Have you ever visited a dentist that had an award on his or her wall that said they are a “top dentist”? Were they nominated as being one of the “best” dentists in the area and have a plaque to show for it?  Ask them who voted.  Did you vote?  Some of these awards may be legitimate.  For instance, local newspapers will run a contest where patients can vote for their favorite doctor.  But most of these things are phony paid advertisements.

I frequently get solicitations that I’ve been nominated/voted as a “top dentist” from some ambiguous company.  For a fee, they’ll send me a fancy plaque to mount in my office.  The only apparent requirements for this prestigious award was that I graduated from dental school, have a pulse and a credit card number.

I see this as just another way professionals are eroding away the trust that society has given us.  If you can pay for these awards, shouldn’t you disclose that? If you legitimately won an award, great.  Let your patients know.  But if you paid for the award to impress others, that’s kind of sad.

3 Dental Habits That Will Save You A Lot of Money and Discomfort

 

Habit 1 is obvious:  brush at least 2 times a day, preferably with a fluoride toothpaste.  Some say brush after every meal.  I don’t even do that.  If you can brush after breakfast and before bed, that would make most dentists and hygienists happy.

Habit 2 is also pretty obvious but is done way, way less then Habit 1.  That’s flossing.  At least 80% of what I fix is decay between teeth.  Maybe more.  Nobody really likes to floss.  It’s much more tedious than brushing.  But it pays much larger dividends to floss.  Not only do most cavities start between teeth, most gum disease starts between teeth as well.  It would be nice to floss twice a day just like brushing.  The more the better.  But if you can at least floss every day before bed, that’ll go a long way to improving your dental health.

Brushing and flossing protect you from bacterial and chemical attacks to your teeth and gums.  But your mouth can also be under attack from excessive mechanical/chewing forces.  That’s where Habit 3 comes in:  wearing an occlusal guard.  Call it a night guard, grinding guard, occlusal guard, clenching guard, mouthpiece if you want but they are all similar and usually look like this:

occlusalguard

Not all patients need Habit 3 but I’m going to say the number that do are now in the majority.  I’m not sure if we’re more stressed today or perhaps we’re better at detecting the signs and symptoms that require an occlusal guard.  Let’s look at some teeth that would benefit from a guard:

bruxism2

Do your teeth look like these?  This patient grinds their teeth.  Unless they are going in there and using an emory board or metal file, there is no way teeth get flat like that from normal chewing, especially in a younger patient.  Something else is going on here.  And if it’s not caught early, you can end up looking like this:

bruxism

When it gets to this stage, it’s the cost of a Cadillac to fix.  All the teeth need to be crowned to regain the height they once were.

An occlusal guard protects not only the grinders but the clenchers.  Clenching is harder to detect.  There is minimal tooth wear.  But you may be having vague pain that is not traced to a cavity or broken tooth.  Another telltale sign is losing gum tissue and tooth material right at the gum line:

recession recession2

 

When you clench your teeth, your teeth flex.  Teeth are like marble and they are not designed to flex.  Marble chips.  So do teeth.  Also, the body doesn’t like this force and pulls the gum and bone tissue away.  That’s bad because gum and bone are the only things holding your teeth in your mouth.  Trying to regain gum and bone requires expensive surgery to fix.

In summary:  brush, floss and put your guard in when you go to bed (or during the day if you catch yourself grinding or clenching).  Your mouth and wallet will thank you.

(all photos obtained via Google Image search)

“My last dentist says I have 5 cavities, you say I have 6 (or 4)”

 

Dentistry is so hard to diagnose decay sometimes. There it is. The truth. In dental school, we were taught that if our little hook thingy (the “explorer”) stuck in a groove, it was a cavity. Didn’t matter if it looked dark or not. We were also taught that cavities on the flossing side of the tooth should be treated when they reached the softer, inner part of the tooth (the “dentin”). Oh, if only diagnosing decay were that easy…

The older and more experience I get, the more I realize that dentistry can be one big shade of gray. Diagnosing is changing. I’ve opened up teeth with a little stain on them to find HUGE mushy decay underneath! I only opened them on a hunch based on the patient’s diet, home care, etc. I’m glad I did!  Otherwise, a root canal and crown would have been needed in 6 months. The problem in dentistry is that sticky grooves and x rays are not fool proof. There are many other things to be considered.  Some docs are up to speed on this, some are not. And no matter how many factors you look at, there will always be some ambiguity.

When I see a patient for a second opinion, I really want to try to diagnose the same amount of cavities as the previous doctor. I really do! It just makes it less awkward for everyone involved. Of course, I have to be honest and have a reason of some sort to diagnose a cavity on a tooth. What happens though is sometimes I don’t arrive at the right number. There are usually a couple “gray area” teeth that could have cavities or not…I’m not sure!   Here’s the funny thing. If I diagnose less, the patient almost always stays with me. But sometimes that other doctor knew something about you that made his treatment plan a little more aggressive. And sure enough those “gray area” teeth need to be treated in 6 months or so. Such is the nature of diagnosing cavities.

Let’s talk about the elephant in the room. You’re coming to see me for a second opinion because you don’t trust your last doctor. That’s the only reason. Okay, maybe the second reason is that she or he is really expensive. But you’re probably afraid he is diagnosing things that are really not there to make money. Guess what? This for sure happens. There are some treatment plans I see where this is obvious. But really it’s not that common. Most treatment plans I see are pretty fair. Yes, some teeth can go either way and I try to explain this to the patient. I’m sure people left me for the exact same reason so I try to be aware and explain the subjective nature of dentistry. You never want to bad mouth another doctor as you rarely have all the information and eating crow tastes terrible.

Here’s something else to think about. Moving around offices until you land in Dr. Not Looking’s office is not a very good strategy either. It does no good for a dentist to “watch” everything until it turns into 5 root canals and 5 crowns for $10,000. Did you really come out ahead on that deal?

In dentistry, you have to trust your doctor. You have to realize that there is a subjective, ambigious nature to much of dentistry.   But you need to know that your doctor is trying to navigate this with your best interests in mind. It seems the older I get, the more shades of gray I see.

Does “Do you take my insurance?” equal “Are you in-network?”

Do you think the above means the same thing? Most patients do. But it really does not. When you call a dental office and ask, “Do you take my insurance?” without asking any additional questions, almost 100% of the time they will say “Yes”. But are you and that office agreeing on what that means?

Let’s define some things. “Taking insurance” just means that the dental office will file a claim to your insurance on your behalf. They are free to charge what they want and what is not covered by your insurance, you pay. They are not tied to any fees dictated by the insurance company.

What does “in-network” mean? It means that your insurance company has already negotiated the fees on your behalf and that is all the dental office can charge. Usually, this means it’s more affordable for you. I say usually because there are some shenanigans that offices pull in order to charge you more than necessary but that’s for another article. But generally, you pay less.

So, was the office you went to lying when they said they took your insurance but after a few visits you realize that they were not in-network? No. But it might be a good public relations move for these offices to explain the differences on the front end. In their defense, you’re ultimately responsible for what plan you purchased. Dental offices are not obligated to walk you through your insurance plan. But we usually do it as a courtesy.  Dental plans are incredibly confusing (even for us and we deal with them daily).

Here’s another thing I hear: “I wasn’t allowed to go to my last dentist because he is out of network”. Not true! If you liked the guy and the staff, you can still go there! The insurance company police will not track you down and throw you in jail! Unless you made a radical change (like going from a PPO to and HMO), you can still see the doctor you like and use your dental benefits. Yes, you may pay a few bucks more but it may be worth it to you!

Why wouldn’t all offices be in-network? Because some insurance plans are just plain lousy. To be profitable, the dentist would have to cut corners on your actual treatment or schedule you next to ten other people and you get to wait an hour to be seen.   People think that healthcare is immune to basic economic principles. It is not. In healthcare, just like everywhere else, you get what you pay for.

We are in-network with many plans that allow us to do top quality work at reasonable fees. But we are not in all the plans for the reasons above. We occasionally drop plans and add some plans. The nice thing about dentistry in the US is that you have to freedom (still) to see any doctor you want. domain list . You may have to pay a little more, but if you like the doctor and staff, it’s well worth it.

In conclusion, if being in-network is very important to you, then ask, “Are you in-network?” In our office, this is sorted with the first phone call.

What are those weird glasses my dentist wears?

loupesWhen you come to see us, you’ll notice that we are usually wearing glasses that have tubes sticking out of them.  The look like miniature microscopes.  In fact, that’s exactly what they are. They are called loupes and they are commonly worn by surgeons to enhance vision.  With these glasses, we have the ability to see in great detail. Teeth are really small. Trying to do exquisite work in the mouth on these tiny teeth is very difficult with normal vision. The following shows what teeth look like under various levels of magnification:

DFV

 

If your dentist is committed to doing great dentistry, then he most likely wears loupes of some sort when doing your crowns and fillings. Well done dentistry lasts longer and it can only be done if the doctor can see in great detail.

Also, wearing these loupes improves our posture so we don’t develop back and neck issues later in life. Not a direct benefit to you per se, but it is for us! (Photo source: Designs For Vision, Inc)

We’re a Plainfield Practice

Dentistry has gotten so varied and complicated that many practices tend to fall into a niche of some sort. For instance, some dentists cater just to people that are in pain. Their practice is almost like an emergency room for dental problems. No appointments needed. Also no cleanings either. Some cater to patients that need a lot of teeth removed and dentures made. No saving teeth- they are all coming out. Some cater to smile makeovers and transforming your smile into that of a movie star. Michigan Avenue in downtown Chicago comes to mind. Every practice seems to fall into a category of some sort.

What do we focus on here in Plainfield? Mom! Let’s talk about Plainfield for a moment. Plainfield is suburbia. It’s “soccer moms” with kids.  I’m married to one.  It’s also home of the soccer mom’s parents and grandparents.  It’s not a place you pull your teeth when you’re 18 (trust me, there are areas of Illinois where this is exactly what happens).  Plainfield is a place where people value their teeth and don’t want to go missing a front tooth. Again, there are some areas of Illinois where this is totally fine. Here, people want their teeth and they value good dentistry. And they want it to look good but they also don’t want Michigan Avenue fees. Our average patient is someone we see twice a year for a cleaning and check up.  Usually, they need a few fillings and perhaps a crown every so often. Some may need a root canal or a tooth removed and an implant placed. That’s probably 80% of what we see.  Do we do cosmetic cases?  Yes.  Actually, we treat every filling and crown like a cosmetic case but we are family dentistry first.

Therefore, we cater to mom.  That is our demographic.  We see families. We have a large hygiene and preventative program.  Mom and son and daughter get seen at the same time usually.  Prevention is the name of the game for us. We do cleanings, fluoride treatments and fillings all day, every day. Believe it or not, some doctors are “above” doing fillings. They want to venture into complex dental surgeries, full mouth rehabilitations, orthodontics, etc. That’s great but that’s not us!  We like doing routine fillings, crowns, restoring implants.  It’s those things we see on a daily basis. Making a tooth look like a tooth again is always a challenge and we like that.  One good front filling can transform a smile. Of course, we have the ability to treat more complex issues but we usually get other experts involved that cater to those needs.

The fact that we stick to what we do really well means we can usually offer those services at a lower fee. In dentistry, this basically means we are in-network for popular insurance plans. Or if you have no insurance, the fees are simply lower.   Good dentistry but minus the Michigan Avenue fee.

Treatment at the Dental School. Good Idea? Great idea!

 

I recently had an older patient come in that wanted a new lower partial denture (a dental device that hooks false teeth to existing teeth).  After the exam, it was determined that only a full denture would work long term for her.  She knew that a lower denture was going to be a big compromise and was adamant that she didn’t want one.  Her next option was a denture supported by implants.  By getting two dental implants, her lower denture would be much more stable.  The only problem was that these were going to add a couple thousand dollars to the treatment.  Even after some discounts, figuring out a payment plan and other options of financing, the patient said there was simply no way she could afford the treatment.   I knew a new partial denture would not work and I also knew the patient would not be satisfied with a complete lower denture with no implants.  So I offered her a referral to a place I believe can help her get what she wants.

Is treatment at dental school a good idea?  No, it’s a great idea!  All schools have clinics where 3rd and 4th year students treat patients.  You may think that you wouldn’t want a student working on you but these students have had countless hours working on mannequins and shadowing dentists before they get to see patients.  And many patients forget that these students are getting graded and they all want to get an A!  Also, you have a seasoned dentist looking over their shoulder, guiding them every step of the way.  Another advantage of a dental school is that fees are usually lower than at a private practice.  The only thing you give up is:  convenience as the school may not be in your neighborhood, a possible waiting list to get treatment, and treatment that may take 1-2 visits in private practice may take several visits at a dental school.  But the dental treatment itself is top notch.

When I have patients that simply can’t afford the treatment they desire, I usually recommend the dental school.  In the Chicago area, we have a school downtown (University of Illinois at Chicago) and one in Downers Grove (Midwestern University).  This option usually works well for retired patients that don’t mind treatment taking a little longer or going in for multiple appointments.

Do Sales Quotas Belong in Dentistry?

 

The landscape of dentistry is changing and patients may not be aware that they are at risk.  Dentistry’s history in the US has been primarily a history of privately owned dental practices.  Your doctor owned the practice.  The fees you pay would go directly to running the business, paying the staff and anything left over would go to the doctor.  The doctor owned the office (and maybe the real estate) and made decisions free of outside influence.

Let’s fast forward to today.  A new thing has gained traction in dentistry:  the rise of the corporate practice.  Outside investors come in and hire doctors as employees.  The doctors are not the owners.  It may appear as a private practice but it is not.  The owners/investors could be several thousand miles away.  The office could even be traded publicly on a stock exchange.  Some offices like these are easy to spot.  They are a “chain”.  Other offices don’t wish to let on that they are run by some distant company.  They model their office to look like a typical private practice dentist.

How does this affect you?  Well, corporations have large expenses.  They have to pay middle managers, upper level managers, a large marketing department and pay for a large headquarters.  And none of the managers actually do any dentistry.  Only the dentist and the hygienist are producing the money necessary to support all this.  And what if the corporation is publicly traded on a stock exchange?  The goal of any stock is to produce a profit.  It’s not necessarily to offer the best oral health solutions to patients.  I’d love to say that the two can go together but I’ll let you decide.  Would you feel comfortable if your doctor had a sales quota or production goal pushed by middle and upper level managers that are in a constant pursuit to increase “the numbers?”  Do you see a conflict here?  To be fair, I’ve heard this tactic being used in both corporate and privately owned offices.  But it seems to be much more common in a corporate setting.  I know of several corporate CEOs that have their own Lear jets.  I don’t know of any private practice owners that do.

All businesses need to make a profit.  Nobody wants to work for free.  But healthcare is unique.  All doctors take the Hippocratic Oath which says we will do no harm to a patient.  This also means no unnecessary dentistry for the sake of money.   I for one do not want to see outside influences trying the bend the rules or put pressure on employee doctors to do things that are not right.  And you should also be concerned- it’s your money and your mouth.  If you think this doesn’t happen, you can learn more by watching the following PBS Frontline episode: http://www.pbs.org/wgbh/pages/frontline/dollars-and-dentists/.

The good news is that the majority of dental offices are still privately owned and the owner is in the building and treating patients.  If you’re not sure what kind of office you’re in, ask.   If you have an issue, the owner doctor should be available to help you.  It’s his name on the door and it’s his reputation on the line.

For some patients, they could care less about any of this.  If the corporate office is advertising cheap dentistry, that’s all that matters to them.  They don’t see past the coupon (although in the long run, private practice can usually offer lower costs simply due to not having to pay all that corporate overhead).   For other patients, they see the value of doing business with people in their community where the doctor is the only one making the decisions in regards to their health.

“My Husband Says I Don’t Grind My Teeth”

I’m not sure our society is going in the right direction.  So many people are stressed out these days.  Maybe it’s the economy.  Maybe it’s because the news is always negative.  Who knows?   All I know is that I see so many of my patients that are grinding and clenching their teeth.  And it’s very simple to see.  Are your teeth flat in the back?  Are they flattened or straight across in the front?  That’s not normal.  You’re a grinder.

“But my husband says I don’t grind my teeth.”  I hear this a lot! Ok, why exactly is your husband watching you sleep at night?  Shouldn’t he be sleeping too?  Also, who says grinding makes enough noise that someone else should hear it?  And who says that grinding occurs the moment you fall asleep and continues nonstop until you wake up? I think many people believe grinding is similar to a cow chewing a cud of grass all night long.  It’s not really like that.   It normally happens in short bursts and a spectator can’t even identify that it’s happening.  Some people are noisy grinders (kids especially!), but that’s not a requirement.  Also, people can grind during the day and not even be aware of it.  When I’m concentrating on something really hard, I find that I start to clench and grind my teeth.  See, I’m not normal either!

How do I know you’re grinding?  You’re missing parts of your teeth! They’re flat, like a table top.  Teeth are supposed to have points and ridges.   Unless you’re filing them down with an emory board or a metal file of some sort, where are the teeth going?  And when you grind your teeth, especially teeth with fillings, they break.  This means crowns.  And when you have ground your teeth down to short stubs, there’s really nothing easy that the dentist can do to fix them.  It’s a $40,000 full mouth dental rehabilitation.

Or wear a $400 dollar custom fit night guard and prevent all that in the first place.

The Low Down on Low Cost Dentistry

 

There was a time when advertising in Dentistry was illegal.  You couldn’t do it.  The Dental Board would allow a small sign saying you were a dentist and that was it.  It was either in the 70s or 80s when the rules changed.  Wow, and have they changed!  This blog is advertising.  This website is advertising.  It’s everywhere.  We are constantly being bombarded with ads in the paper, in the mail, Google, Facebook, on cars and even on the back of shopping carts.  There is a practice in Florida that pays a guy to spin a big tooth next to a busy intersection (I didn’t say all advertising is in good taste).  Some patients would be attracted to that office.  Others wouldn’t dare set foot in it.

Let’s specifically talk about promotions attached to fees.  Are they too good to be true?  I see ads for implants done for $999.  That’s about 40-50% lower than average around here.  It sounds great!  If I were a patient, why would I want to pay more if that doctor is going to do the job for less?  Is it too good to be true?

Well, it comes down to the details.  Most dental offices allow patients a certain amount of goodwill.  What I mean is if an implant fails, a new one is usually done at minimal or no charge.  If a crown breaks within a few years of placement, it’s usually redone for free.  Dentists are under no obligation to do any of this from a professional  standpoint (has your MD ever given you a refund when the drug he prescribed didn’t work)?  But we do it because it’s good business.  Now if you search out the doctor doing work for way less, are you going to get these benefits?  You better ask.  Will the doctor stand by his or her work?  How are complications handled?  Are the parts he uses made in the US?  Does that matter to you?  What’s his reputation in the community?  Will he file insurance for you?  Most importantly- will he be there in the future in case something happens?

Offering lower cost dentistry by increasing efficiency is great.  Eliminating redundant steps lowers costs.  Negotiating with your product suppliers lowers costs.   Maximizing the hours of operation lowers costs.  We can pass these savings on to patients with no loss of clinical quality.  There is a right way and wrong way to lower costs in dentistry.  Just be aware of the methods your doctor may be using to offer low fees.