Seems like I use this blog mostly to vent about things I read that bother me (or to announce something I'm doing with my writing).

The latest is this article about The Shame of Poor Teeth in a Rich World. Not so much the article itself. It's hard to argue with many of the things the author writes. For example, it says this: "In 2007, the New York State Dental Journal reported that while only one-tenth of general physician costs were paid out of pocket, nearly half of all dental costs were settled directly by patients." While this is certainly true, it's also a distortion of the same facts it reports. Because what it doesn't mention is how much money is spent on dental services compared to medical services. Now I'm probably going to get the exact percentage wrong, but last time I saw a number, I believe it was 4% of total medical spending in the country. For every dollar spent on medical care, 4 pennies are spent on dental care. That's ALL dental care, including out-of-pocket and insurance spending.

What does that say to me? It says that while ten pennies out of every dollar are coming out of patients' pockets for medical care (ok, 9.6 pennies), 2 pennies are coming out of their pocket for dental care.

It goes on to say this: "This reflects spending by the uninsured but also those sharing costs with coverage providers; most plans cover routine cleanings but leave patients to pay for 20 to 50 per cent of fillings, crowns and other big-ticket visits. For those who can’t afford to pay that difference, treatment is delayed and teeth continue to degrade." Again, true, but did you catch the first part? The part about most plans covering routine cleanings? Because the truth is, they don't cover only "cleanings" but they also cover diagnostic procedures such as radiographs and complete periodic examinations, including oral cancer screenings.

How do dentists find problems? With those "free" (to the patient) x-rays. How do we prevent problems? By removing the bacteria that cause tooth decay and periodontal disease. How do we remove those bacteria? Through those "free" cleanings. How do we detect oral cancer and some cavities? By the "free" visual examination process.

These common dental diseases are preventable. That's the big thing that no one seems to want to mention in any article. Is it expensive to prevent? Not as expensive as treating it once you have it. It takes:

• a toothbrush


• floss and/or interdental cleaners (softpiks, ie)


• 5 minutes twice a day


• 2 visits to the dentist

In our office, we provide a toothbrush, floss and some interdental cleaners with our recall appointment. We also provide some instruction as well as a complete examination and a dental prophylaxis. If you have healthy gums and teeth, that's the extent of it. We see you twice a year and you give us probably about $350.00. If you have dental "insurance," more likely you give us nothing and your plan pays it all.

Let's say we find a cavity. Let's say it's between the teeth and it's relatively small. In my office the cost is around $200.00. If you have "insurance" you pay your deductible (typically $50.00) and your 20-50%, usually 20%. That means you hand us $80.00. I went out to eat at a PF Changs over the weekend and our meal for 4 was just a little more than that. And the place was packed (we had to wait about 25 minutes) and everyone was ordering food and drinks.

I don't think they all had perfect teeth.

The last part of that quote: " For those who can’t afford to pay that difference, treatment is delayed and teeth continue to degrade." "Afford" is such a loaded word in itself. Can anyone afford to buy a car? A TV? An iPod? (An awful lot of people who can't "afford" dental care seem to have iPads...)

It seems to me that it's more about placing value on things. TV and iPads are "valuable" to people. Their teeth very often are not valuable to them. I've had patients tell me that "as long as their insurance paid for (x procedure), we could go ahead and do it." No mention about them wanting to do it, or valuing the procedure because they wanted to save the tooth. That's a huge key.

We don't take Medicaid or public aid at our office. Why? Because, as the article said, of the low reimbursements. That said, I've NEVER turned away a patient who had a true dental emergency (like an abscessed tooth, or a broken off front tooth) for reasons of not being able to pay. I simply do the emergency treatment and hope for the best with respect to the charges. If I get nothing, I'm okay with that. But I don't want a steady stream of patients filling up my schedule where I'm getting reimbursed 10 cents on the dollar. I operate at something around 65% overhead, not including my own salary. Throw in my salary and it's a lot higher. I simply can't spend my day treating patients who actually COST me money to treat. If that makes me cold or callous, so be it. I have kids, too. They cost money. I have to pay for their medical insurance and their health care and their educational needs and all that stuff, plus funding my own retirement and meeting my own day to day costs. Sucks to be poor? Sucks just as bad to be middle class these days.

Here's another emotional quote from the article: "About a decade ago, at the age of 50, my dad almost died when infection from an abscessed tooth poisoned his blood and nearly stopped his heart. He has never had dental insurance and has seen a dentist only a handful of times when some malady became unbearable." I hear things like this a lot. "I didn't have dental insurance till now, so I haven't been in for 5 years." If I hear something like that less than once a week, it's a slow week. I always think about it like, "how does the fact that you don't have dental insurance prevent you from going to the dentist? If you break your wrist or you begin coughing up blood, do you forego a trip to the doctor because you don't have medical insurance?"

An abscess that causes a serious problem like that is probably long-standing and has let the patient know several times that it is there. What did he do at those times? Call his dentist and report swelling or pain, get a prescription and never follow up by actually going to the appointment that the office almost certainly insisted upon? The idea that one cannot seek treatment because he doesn't have "dental insurance" is just another way of deflecting responsibility for your own condition onto another.

I liked this quote too: "I point out that Gatorade, which he favours when he splurges on a bottled beverage, is full of sugar. But it wasn’t sugar, heaps of which are sucked down daily by the middle and upper classes, that guided his and my grandma’s dental fates. And it wasn’t meth. It was lack of insurance, lack of knowledge, lack of good nutrition – poverties into which much of the country was born." I like Gatorade sometimes, too, but I recently saw a patient walk in with an open 20 oz bottle of Mountain Dew. At 10 am. I jokingly told him that I see he was drinking his bottle of liquid tooth decay. I also told him that with his history of dental problems, that Mountain Dew in the morning was probably not the best idea. Should I have been more forceful? Maybe, considering that his response to my comments was to brush them off and ignore them as much as possible.

I don't think there's a person in this country who doesn't know that you're supposed to get your teeth cleaned twice a year (and brush with Pepsodent!). Yeah, it came from a Pepsodent commercial and has no real basis in research, but the fact is that for many patients twice a year seems to be about right. For many others, 3 or 4 times a year would be better. For a small number, once a year is enough. For another small group, they'd probably be best coming every other day for the rest of their lives. When patients are here, they get educated. We used to provide lots of brochures about various topics, but we noticed that no one was taking them and when we handed them to people, we would actually find them in our waiting room, left on the front desk or on the sofa, or in the parking lot on the ground. I quit spending money on them. Now I just try to educate face to face. How important is it? It may be the most important thing we do, but it is certainly the least valued. We used to have a small (like 5 dollar) fee for oral hygiene instruction. Dropped it when patients told us that we weren't doing anything but talking to them and charging for it. (To which I would think in response: yeah, same thing a psychiatrist does...)

Point is, you can't educate an adult (or a child) if they're not interested in what you're teaching.

Another quote: "Common throughout those years was a pulsing throb in my gums, a shock wave up a root when biting down, a headache that agitated me in classrooms. While they looked OK, my baby teeth were cavity-ridden. Maybe it was the soy formula in my bottle when they were growing in, or the sugary cereals to which my brain later turned for dopamine production in a difficult home. Maybe it was because our water supply, whether from a rural well or the Wichita municipal system, wasn’t fluoridated. But richer teeth faced the same challenges. The primary reason my mouth hurt was lack of money." No, I would say the primary reason your mouth hurt was dental neglect. Due to lack of money, or due to lack of perceived value? I wasn't in the house so I don't know how they lived. I know there is more information available today, more treatment options (I worked at both a county health department treating kids from 3 to 14, and I volunteered at a local free clinic treating adults and children) and better food availability at schools (give Michelle Obama at least a modicum of credit for that last part). But all you can do is look around and figure out where the value was placed in your own life.

Now we get to the best part of the article (and I mean that sincerely): "When a health teacher said brush your teeth twice a day, I brushed my teeth twice a day. When a TV commercial imparted that dentists recommend flossing daily, I flossed daily. A college room-mate once remarked on the fervour of my dental regimen. After boozy nights, when other kids were passing out, I held on, stumbled to the bathroom and squeezed paste onto a brush. However tired, however drunk, I scrubbed every side of every tooth, uncoiled a waxed string and threaded it into sacred spaces." So what she is saying is that, if she takes care of her teeth, they stay healthy! And the beauty is that anyone can do it!

She ends the article by saying this: "For the American Dream to put its money where its mouth is, we need not just laws ensuring, say, universal dental care, but individual awareness of the judgments we pass on people whose teeth – or clothes, waist lines, grocery carts, or limps – represent our worst nightmares." Before we get any of those things we need people, normal people like all of us, to place value on the health of their teeth and gums. To realize that "just pull it" is not optimum dental care. To realize that getting a denture is the patient's failure, not the dentist's or the system's failure.

I hated the few comments I could stomach to read, stuff about insurance driving up costs and dentists charging too much, and I just thought that there's a lot of lack of knowledge out there about everything, and when you shoot off your mouth saying things like that, it just makes everything you say about EVERYTHING suspect. (For the record, insurance has been a force for keeping fees low in general dentistry and in general medicine -- though not so much in specialties, in my view.)

Long entry, I know, but I just had to rant. Sorry.

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