SAN FRANCISCO (CBS.MW) -- The next time you climb into a dentist's chair, take note of the advice you're given. You may be taken to the cleaners when you thought you were in for a cleaning. The dental profession's mission is to treat decay and alleviate pain, but it's now confronting a rot in its own ranks that's producing discomforting financial consequences for millions of patients. Treatment to excess, promotion of cosmetic dentistry, marketing of unproven "technological advances" and transfer of dental practices to lower-paid hygienists and assistants are undermining a profession that historically has enjoyed relatively high public regard, the pain involved notwithstanding. While the vast majority of dentists are above reproach, two major developments are leading many toward patient exploitation and factory dentistry: A sharp decline in cavities and a dwindling number of practitioners, who can mask self-interest since they're mainly in solo and small group practices. "Dentistry is very much a cottage industry that unlike medicine hasn't consolidated into large groups that work on guidelines," said Dr. Craig Amundson, dental director for HealthPartners, a 60-dentist practice in Minneapolis. "We're too quick to focus on patients as individuals rather than an organized system we can bring to bear." However they set fit Consumers trying to determine if they've found one of the good ones face two complications: The profession is largely self-regulated and, more significantly, it lacks recognized standards of care. In other words, one dentist may suggest treating tooth decay with a new less-invasive technique called remineralization, another might recommend a deep filling, a third might suggest a crown and a fourth might say supportive bridgework also is in order -- and all four would have defensible positions in the eyes of the profession. "There just aren't good prospective, randomly controlled studies" in dentistry, Amundson said. "There is a lack of an organized body of literature for specific treatment recommendations." Surprisingly, dentistry is actually considered a combination of art and science. With the rising promotion of teeth whitening and other cosmetic dentistry -- even Tom Cruise is now wearing braces between films -- the "art" is what many more dentists are selling. "How do you know if a dentist is honest?" asked Dr. Richard Souviron, an expert in forensic dentistry in Coral Gables, Fla., who testifies in malpractice cases. "I'm a dentist and I don't know myself." Cut off Ensuring you're getting proper treatment is complicated by the fact that, unlike medical insurers, most dental plans don't pay for second opinions, experts said. If the treatment seems excessive, you have to foot the bill to find out otherwise. Managed care does serve as a check on over-treatment, but only a limited one. The reason: Unlike medical care, where bills for treatment run into the tens of thousands, dental care isn't nearly as expensive. As a result, insurers' "utilitization reviews" of treatment recommendations aren't as rigorous. The insurer also generally covers only 50 percent of the bill for anything but routine cavities, compared with 80 percent or more for medical care. Another glaring difference between the dental and medical professions is that U.S. doctors capitulated to letting physicians' assistants and nurse practitioners, who hold masters degrees, treat patients for routine ailments. Of course, the PAs must be assigned to a physician's practice, so the doctors still reap the billing benefits. Dentists have fought against granting more duties to hygienists, who are admittedly less trained than PAs. But the number of dentists is expected to dwindle over the next two decades, so it's inevitable more responsibilities will be transferred to support staff. Dentists, who pay their assistants far less than medical PAs, will reap the financial benefit of using more low-cost labor while raising fees as their own labor supply drops. Bad taste in the mouth I must confess to sour grapes over my own stupidity, having been burned in the last year by both a general dentist and an orthodontist. A new dentist I saw last year told me I needed seven crowns. He crowned two adjacent teeth and filled a cavity in a third after one shot of novocaine in a one-hour visit and 15-minute follow-up -- and pocketed more than $2,000 for the work. When I questioned him further, he said all but those two crowns were cosmetic fixes, but since I still had $700 in my flex-spending plan, maybe I'd like to pay $500 to have my teeth whitened? This year, I made the mistake of seeking out a lower-cost orthodontist, who agreed to straighten my boy's teeth for $5,000 over 30 months. On the first visit, she had an assistant put in spacing bands in a five-minute procedure and didn't even pay my son the courtesy of a greeting, let alone outline a treatment plan. When questioned, she acknowledged that her assistants might be handling monthly adjustments -- which worked out to about $150 per 15-minute visit with a dental assistant, and her occasional oversight, for 2 1/2 years running. Consumers don't have many places to turn for guidance. The National Association of Dental Plans, the insurance industry's trade group, doesn't offer any literature for patients so they can gauge when they're being oversold treatment, even though the insurers and consumers are natural allies in this cause. So what's a consumer to do? Here are some recommendations: - Be skeptical: A new dentist who immediately recommends extensive treatment well beyond your old dentist's treatment plan should be immediately suspect. And be especially suspicious if the new dentist doesn't call your old one for a consultation.
- Be selective: "Ask a lot of questions, shop around and, if you're getting the feeling the dentist is not spending time with you, that's a red flag," said Linda Sherry, spokeswoman for Consumer Action, a San Francisco-based education and advocacy group. "Someone wanting to take a full head of X-rays right off the bat or suddenly recommending all kinds of dental work, this is not the norm. There's nothing wrong with delegating certain tasks to lower-rate assistants, but that should come through in the price you pay. And asking other people for recommendations is a much better way than calling 1-800-DENTIST, where the dentists are all paying to have their names listed."
- Seek a no-cost second opinion. Many dentists will waive an exam fee for a second opinion for the prospect of gaining a patient, Souviron says. "But when you get a second opinion, don't disclose what the other dentist said. 'This guy's ripping me off, he wants to do seven crowns. Here are my X-rays, what do you think?' You want a blind study."
- Tap an ally: Gail Shearer, director of health policy analysis for the Washington office of Consumers Union, suggests making use of your insurer if you question a treatment plan. "If the insurance company is asking questions for you, that offers some protection."
- Don't settle for less: Expect to be seen by the dentist for anything but routine cleanings, Souviron said. For instance, if an orthodontist is letting assistants handle monthly adjustments of braces, you're probably not getting your money's worth "When I go to a dentist and pay $950 for a crown, I want the dentist to make the temporary, I want the dentist to clean the cement off and I want the dentist to make sure the bite's right."
Consider what Dr. Richard Simonsen wrote last June in a guest editorial in the trade publication General Dentistry: "We must not accept the rush to faster treatment to improve profits, or the cancer of testimonials and infomercials substituting for data. We must not stand placidly by and accept the blatant overtreatment being promoted in the dental tabloids. Dentistry's core values will not tolerate us quenching our thirst for material goods in the trough of public trust." Chris Pummer is personal finance editor for CBS.MarketWatch.com in San Francisco.
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