The 'Irrational' Way Humans Interact With Dentists

http://www.npr.org/templates/story/story.php?storyId=130356647

by jakarta • 16 years ago

119 91 16 years ago

jakarta• 16 years ago

This article got me thinking about a trip to the dentist I had a few years ago. From when I was 5-18 years old I had the same dentist and between ages 13-18 I had a really impeccable record when it came to not having cavities.

Then, when I came back from my first semester of college I had to switch from my old dentist (who specialized in children/teenagers) to a new one.

On my first visit, he identified something like 3 cavities, which was pretty shocking to me. Before I just assumed that the x-rays were easy to interpret so the dentist is 'always right' ... but after hearing about this 50% figure it makes me wonder.

arethuza2• 16 years ago

When I changed dentist after University the new dentist made an official complaint about the standard of work of the previous one (who I had been with since an early age).

For a while my mouth was effectively "Exhibit A" in some kind of professional complaints process.

CWuestefeld2• 16 years ago

Given the content of the OP, is it possible that the problem wasn't so bad, that this was all a marketing device, building the relationship between you and the new dentist?

jordan0day• 16 years ago

Warning: Post is 100% anecdote; Cite at your own risk!

My wife had a similar experience. We both grew up in a small city, and throughout her life she never had a single cavity. She prides herself on the health of her teeth.

In college we both moved to a larger city (which has a more competitive dentistry market), and suddenly dentists were finding cavities every time she went for a checkup.

While it's entirely possible that she didn't have cavities before, and now does all the time, I feel like the competitiveness of the market here has lowered the standard of what actually requires a filling.

That is, in our hometown, a dentist could take a more measured approach -- if something looked like it could develop into a problem but wasn't currently one, they had the leisure of waiting for the next six-month checkup to reevaluate. Here, it seems to be the equivalent of shoot first and ask questions later.

Also, every filling I've ever had never came as a result of actual pain or discomfort, they only occurred because I went in for a regular six-month checkup. Given my wife's experience (going from apparently perfect teeth to requiring fillings at nearly every checkup) I can't help but feel about as confident as a woman at an auto shop hearing "You need your blinker fluid replaced".

alaithea• 16 years ago

> Also, every filling I've ever had never came as a result of actual pain or discomfort, they only occurred because I went in for a regular six-month checkup.

FWIW, I've heard that by the time you have pain or discomfort in association with a cavity, it means it has reached the nerve, which indicates a root canal at that point, rather than a filling. So, getting cavities filled before they hurt is important.

ezyang• 16 years ago

The story I've always heard about this is that as you grow older, your immune system becomes less active in defending your teeth, and so you have to correspondingly brush more often to maintain teeth health. So if you're brushing the same amount as you were as a teenager, you will get more cavities. I don't have a citation though.

ekanes• 16 years ago

Areas like this (essentially, a complex combination of psychology combined with differing motivations along with a little information disparity for good measure) could be an interesting opening for a startup.

If you could get over the admittedly uncomfortable social dynamic of implying a lack of competence in your dentist, you could ask them to send your Xrays over to "2ndopinion.com" where trained and certified dentists would give a second opinion. You might pay $80 for the privilege, and for that price maybe 2 dentists would review it.

Anyways, you get the idea. I love disruption around information disparities.

stellar678• 16 years ago

Or just crowdsource the reading! It would be really interesting to check out the aggregated quality of this kind of technique.

olefoo• 16 years ago

If by crowdsource you mean have multiple dentists look at every image set, then maybe. But if you're suggesting that a random selection of people look at dental x-rays and guess where the cavities are... that would be an interesting experiment, but I wouldn't expect too much.

In either case, I doubt you'd find much traction since looking at dental x-rays isn't something most people are going to want to do on a regular basis without being compensated.

almost• 16 years ago

I just came here to post the same, I think that could actually work. Maybe there's some other value add that could be done that would make it not just a straight "I don't trust your opinion" thing. Like maybe it's useful to have these things stored so you can see something or other over time. The second use doesn't need to be hugely useful, it's just a polite fiction for the patient-dentist interface :)

Dickdavis• 16 years ago

Reading this while sitting in a chair waiting for four cavities to be filled might not have been the smartest move.

rikthevik• 16 years ago

Certainly not the most relaxing move. :)

lunchbox• 16 years ago

I think it is the smartest move, as long as you act on the information properly.

timcederman5• 16 years ago

I have no problem shopping around dentists, and have even checked my new dentist's professional opinion with my old dentist who I trust completely (I moved overseas). I studied how dentists work with their computers for my PhD using participatory design so learnt the basics of dentist practice, and from my studies at a dental school, got to learn what good and bad dentistry are, so I'm definitely not the norm.

It is interesting how devoted most people are to their dentists. I was referred to a dentist who was TERRIBLE. Really really bad. And the person who referred me had referred a whole bunch of people who all went there (which is why I trusted the referral). I never went back, and started asking other people what they thought - everyone had doubts about his skills, but still went. This article is an interesting way of explaining why they kept going regardless of the terrible experience and lack of competence.

probablycorey• 16 years ago

Where do you live and who is your dentist!

timcederman5• 16 years ago

I live in the Bay Area. If you email me I can let you know my current dentist.

jojopotato2• 16 years ago

Do you have any pointers on what to avoid?

timcederman5• 16 years ago

The main areas I evaluate are:

- technique (one of the most important, but generally difficult to interpret without some tuition. However some good indicators are time spent in mouth during procedures, how prepared is the dentist (hunting for tools is worrisome), level of pain, number of times work has had to be fixed)

- hygiene (appropriate glove changing, mask, tool use and sterilization). The most obvious things I notice are whether tools are coming out of sterilization bags and being placed on a sanitized surface. Does the dentist return a tool that's been in your mouth back to the sanitized surface?

- equipment (age of equipment, tech levels (not too high - don't forget, you the patient are paying for it). This is also important as digital x-rays use much less radiation and allow for immediate review with the patient.

- patient manner (attentiveness to pain and mouth discomfort, willingness to answer questions and properly explain procedures, or even minor things like accommodating patient embarrassment of tooth condition)

- upsell (does the dentist try to have you buy an occlusal splint without demonstrating actual tooth wear, sell you on cosmetic surgery, or attempt immediate intervention constantly rather than a wait and see approach)

- preventative methods (often, but not too often periodontal examinations, fluoride treatments, x-rays, etc)

Herring2• 16 years ago

This stockholm syndrome is annoyingly hard to avoid. I've known about it, but I can recall many similar occasions after reading this article.

eru3• 16 years ago

Examples?

jtbigwoo• 16 years ago

Buying a car is a really unpleasant, multi-hour experience, but it's funny how often people go back to the same dealer.

Herring2• 16 years ago

Generally harsh criticism from people with some power over me. No matter how boring the subject matter, this makes me more likely to work at it & to seek their approval.

deadmansshoes• 16 years ago

I would have thought the main reason for changing dentist is when moving to another area.

Cognitive dissonance? Cognitive cacophony.

cal5k• 16 years ago

I think this happens with surgeons as well. About two years ago my doctor found nodules on my thyroid... blood tests revealed Hashimoto's Thyroiditis. After a series of ultrasounds, radioactive iodine uptake tests, and needle biopsies, I was referred to an ENT who specialized in thyroid surgeries.

The pathology report revealed that there was about a 20% chance I had papillary thyroid cancer, which has the highest cure rate of any type of cancer (>95% are completely cured after a thyroidectomy). So he recommended we take it out.

And that's what I did... a partial thyroidectomy where one half was removed. Turned out there was no cancer.

It was weird, though. After all of the painful tests, the long weeks waiting for appointments, the waiting in doctor's offices, the uncertainty, I didn't really think to say "Well, this is pretty low-risk... why don't we just wait on it?"

Surgeons will operate if you let them. It's what they do.

klbarry• 16 years ago

Dentists can be complete crooks though.

All my life I went to two dentists. Both were pretty good, and I had cavities pretty rarely.

Later, my parents had to switch insurance, so we went to another dentist with a much nicer office. He takes a quick look at my teeth and says, "Oh yeah, looks like about eight cavities. We should drill them etc etc"

My parents are shocked and take me back to our most used old dentist for a second opinion. He examines me closely with a pick and tells us the other guy is full of shit, and that behavior is really common in dentistry.

ultrasaurus• 16 years ago

When I worked in the US, I had $1500/year in dental insurance and a new dentist. The x-ray turned up exactly $1500-(2x cost of regular checkups) in cavities. (All of which turned out to be JPEG artifacts & shadows)

protomyth2• 16 years ago

A dentist is the closest thing most of us get to a cosmetic surgeon. They can have a large effect on our appearance and have procedures that will probably cause us the most pain out of anything the normal person has done to them. Plus, they hold up an x-ray and say "This is..." not "This might be...". You really owe it to yourself to get a good look at who is doing the work.

As an example, as a child I was under government health care (Indian Health Service in the US) and "had to have" a root canal done. The dentist did the work (come to find out it is generally someone else who does this). I think nothing of it other than the extreme pain. This is when I was in 6th grade.

1st year of college and I get this incredible pain in my mouth. I go to a dentist (not IHS) and get my mouth checked. Come to find out the original dentist left some infected material in there and I am in a world of hurt. Antibiotics and Percodan for two weeks and then oral surgery. The oral surgeon had some not-so-kind remarks about the person who originally did the root canal.

ugh2• 16 years ago

“Plus, they hold up an x-ray and say ‘This is …’ not ‘This might be …’.”

Ha! My dentist actually said ‘This might be …’ as we looked together at a X-ray. He said that we could be looking at very, very early caries or just a shadow and that X-ray images are always tricky. I will be X-rayed again at the next routine checkup to see if anything has changed.

Incidentally, how common are X-rays in the US? It sounds like they are quite common which surprised me. They don’t seem to be part of the yearly checkup in Germany if I’m remembering right. I think it’s rather a every-other-year or every-three-years thing.

protomyth2• 16 years ago

Very common - I think it is an insurance requirement to get paid.

ubernostrum• 16 years ago

Standard practice here in the US is a full mouth x-ray about once every 12-18 months, because that's what insurance will pay for.

(and my dentist is the same way -- he'll sit down with an x-ray and sometimes photos as well, and go over "OK, this might be the beginning of a cavity, or it might just be a stain from drinking tea/coffee...")

jerf3• 16 years ago

There seems to be a massive disparity in techniques and tools, too, though I am reporting only anecdotally. I recently got dental insurance again after a long time, and for better or worse started going to a dentist again. I picked him via "since I have no other metric to use I might as well pick the closest that takes my insurance". Somehow I stumbled onto an older guy with a lot of experience but who has also kept up with the latest technology.

He doesn't use X-Rays to find cavities, he's got this laser thing that directly measures the tooth density and makes little werping noises when it is low. He found a couple of things (which I had no reason to suspect weren't problems as they were highlighted as problem areas by another guy ten years ago, and one of the other problem areas he said still isn't enough of a problem to be worth doing). It seems a much more objective system than poking at things or looking at X-Rays. I got a couple of filling done via laser drill, which I didn't need anesthetic of any kind for. (Those with low pain tolerances might, it wasn't pain free, but it was OK and I preferred it to a droopy drooly mouth for most of the rest of the day.)

I figured I'd just been out of the game for a decade and a lot has changed but I've mentioned this to my coworkers and few of them recognized any of that stuff. Your anecdotes solicited.

Eliezer• 16 years ago

Can you name the dentist if they're in the Bay Area?

jerf3• 16 years ago

Sorry, he's about 2,300 miles away from the Bay Area. :)

Hmm, may I take this as further evidence that my absolutely terrible selection metric has indeed blundered onto a good choice? (I'm honestly surprised, I honestly thought I had just been out of the loop.)

lgas• 16 years ago

I had a very similar experience and found this dentist (Ravi Sahdev) in Palo Alto to whom I've referred half a dozen or more people from my company to and everyone has loved him. He's so much better than any other dentist that I've gone to that it's hard to describe. And he's very up to date on all the latest advances in dental technology and tools. The website makes it sound like it's primarily for cosmetic dentistry but he does normal family work as well.

http://www.cosmeticdentistpaloalto.com/

dstorrs• 16 years ago

Your dentist wouldn't happen to be in the Bay Area, would he?

Edit: ninja'd

ars2• 16 years ago

That seems to be "Laser Fluorescence Cavity Detection", brand name "DIAGNOdent" (for all the people asking where to find him, I guess you can ask for this by name).

But it's not a perfect system - detection is about 80% to 90%, http://jdr.sagepub.com/content/83/suppl_1/C80/T1.expansion.h...

cdr• 16 years ago

80% to 90% sounds massively better than x-ray.

Bricejm2• 16 years ago

My dentists keep changing because they keep leaving the practice I go to. That might be a sign to look elsewhere. Although my first dentist told me that at some time I would need a crown put on a tooth, and as soon as he left and the new dentist looked at my tooth, he said we should get this done now even though nothing had changed. One could have been complacent, while the other was proactive - who knows. There probably should be more of a standard than a gut feeling when it comes to medical procedures.

jrockway• 16 years ago

I think this is more "the rational way dentists interact with insurance companies". Insurance companies pay well under the usual market rate for treatment, so it makes sense for a dentist that accepts insurance to find a lot of problems that can be fixed in a short amount of time. "Yeah, that's probably a cavity" for 3 teeth on the same side of the mouth requires about as much time-in-chair as 1 cavity, but he gets to bill 3x. And since the insurance company is paying for it, there is no risk of not being paid. (It's bad for the patient, of course, because the fillings have to be redone in 10 years. But that ticking time bomb keeps the insurance payments coming in, and so it's good for everyone. Except the patient.)

My dentist doesn't take insurance and so he probably doesn't do this.

8ren2• 16 years ago

I've tried 6 dentists recently, 2 were local; 2 were referred by people I knew; 2 were referred by health-care professionals who were trustworthy and gave me truly excellent results in their own field. I'm in Melbourne, Australia, and I have no reason to believe that our dentists are particularly bad.

All 6 were either dishonest or incompetent. Including: preventing my front teeth from meeting; modifying opposing teeth for a fit; key equipment not working; charging me for work not done (I was informed that they'd checked the invoice too); going back on an agreement (to give me the xrays); going ahead with work without asking me (I found it impossible to get out of the chair to stop him); and of course being overcharged (my accountant remarked on it.)

However, all 6 were excellent at minimizing pain, and that seems to be what most people notice. I'm more concerned about getting my teeth fixed.

The 2 previous to these 6 were not very good. I would have thought 6 more would be enough to find a good one. I have given up on the dental profession as institutionally corrupt. I do not believe there is even any facility to complain about them, as that would also be run by dentists.

Because it's difficult for a layman to check a professional's work, especially when that work is also difficult to inspect, I used secondary signals in the above. However, I also bought a small mirror, and a direct inspection also revealed a misplaced shallow drill hole (with no filling). I remember years ago one of the previous dentists had slipped, but I didn't think it had actually resulted in any drilling. None of the dentists mentioned this very obvious rogue drill hole.

I think most people are happy to get out of there, and if any pain stops. I just wish I could DIY my own dental work.

Can anyone suggest how I can find a competent dentist?

timcederman5• 16 years ago

Where in Australia are you? If in Brisbane I can recommend several excellent dentists.

For people in the US, Yelp is a good starting point, but it helps to try a dentist once or twice as a trial (rather than going for major work without knowing what they're like).

8ren2• 16 years ago

Thanks, but unfortunately I'm in Melbourne (edited to add it).

Yeah, I've been doing the trial thing also. Maybe I should keep trying, but some were charging $100-200 for just inspecting.

ars2• 16 years ago

Why fill a cavity so early?

Why not wait till it's a bit more obvious? I don't mean wait till it's so bad you need a root canal, just till it's not a "maybe".

sjf• 16 years ago

In don't know if this is typical, but I've never gotten a toothache before it was time for a root canal.

joelmichael• 16 years ago

"Cognitive dissonance is the idea that when people do something painful they become more committed to the goal."

No. Cognitive dissonance is the pain caused by having two contradictory ideas at once.

http://en.wikipedia.org/wiki/Cognitive_dissonance

David• 16 years ago

...which usually leads to a change in understanding or explanation to rectify the conflict. In this case, the cognitive dissonance, paying a large amount of money (by necessity) for a service of unknown quality, is resolved by commitment to the resolutive idea that the service is of very high quality and is deserving of the high price.

Yes, the wording is technically incorrect, but the common usage of "cognitive dissonance" is generally about practical implications, like this.

reduxredacted• 16 years ago

There is a little bit of over-simplifying going on in this article, but it was an interesting read, especially for an anti-dentite like myself. The problem is that people don't go to the dentist just to have cavities filled. My first trip to my current dentist happened due to a severely painful toothache (to call it in ache is like calling a broken leg a paper cut). I had my bride do some research of local dentists (whatever she could cram into 5 minutes on google) and went with the guy that I perceived as having the best technology (but really the main criteria was the most open schedule).

What followed was a great experience: after 2 hours of patching things up, my pain was almost completely gone. After a few days of antibiotics, it was gone. The shot required to numb the area didn't hurt (it may have under normal circumstances, but ... "broken leg"). That single correction brought me back on schedule. I had a filling that was sensitive. He replaced it with a "new material", it was more sensitive, so he replaced it again with a different bonding (Neither I nor my insurance were charged) and that sensitivity went away. No cavity filled since then has been sensitive.

I've had a handful of cavities, and I return, reluctantly, but my loyalty lies more in the fact that I had a tangible, identifiable problem (excruciating pain, and later sensitivity) and he troubleshot it until it was fixed to my satisfaction. I wouldn't see another dentist simply because I believe this particular dentist to be predictable. I'll have a problem, he'll fix it. I, like other commentators, have a dentist who uses more than just X-Rays to diagnose cavities. At the moment, I have three spots on the X-Ray and DIAGNOdent that he has said he'd like to "wait on" because he wasn't sure. I had thought -- due to my past experience with tooth pain -- that "waiting on" something like that was asking for trouble, but now I'm wondering if I have a Dentist who understands the limitations of the technology he uses.

ora6002• 16 years ago

I have about 5 dentists in my immediate family (grandfather, dad, dad's wife, aunt and uncle). My dad is the head of the Perio department in the Hadassah Dental School in Jerusalem. Naturally, I had my teeth checked twice a year like clockwork all my life. I have some gum issues, but never needed a filling.

6 month after moving to the bay area, I went to a local dentist for general checkup. He used the "laser thingy" to find cavities and found no less than eight cavities that required filling. He also took XRays that showed no issues at all. I asked him for copies of the records and XRays so I can send to my father for second opinion. He immediately agreed, but despite weekly reminders, he never sent me the films.

On my first visit back home, I got my teeth checked by my aunt again. I need one filling.

Lessons learned: * US diet accounts for one cavity. * Dentist greed accounts for seven more. * Always ask your dentist for copies of XRay and files and don't return if he will not supply them. It is your right to have those copies of your dental history. * If the XRays don't show the cavities, there are not at a level where you need to treat them yet. You can safely wait until they show up. If you maintain high level of dental hygiene they may never get to the point where they need filling.

mistermann2• 16 years ago

Since you have so many dentists in your family, can you (or anyone else here) comment on the cost of dental care?

Every time I go, I am absolutely floored by the prices. I haven't been for several years now as I've had no pain requiring immediate attention.

My last experience with dentists was getting a tooth that had cracked in half examined. At that point I had some pain, but I use sensodyne toothpaste so it seems to have healed over the crack. I can't recall the exact numbers, but I first had my regular dentist look at it, who then sent me to a specialist (oral surgeon I believe). I seem to recall the combined charge of these two visits was almost $1000 (this is in Canada, fwiw). Total time in chair was far less than 30 minutes....I recall calculating the hourly cost was >$2000/hour. The estimate on "building the tooth back up" (not pulling and replacing with ceramic) was around $3000-$3500 (for I think around 45 minutes work).

Teeth cleaning is less, but on an hourly basis, it is just ridiculous. And of course it seems to always come with the unrequested inspection by the dentist, < 5 minutes for $75 (likely much more now).

I just can't fathom how working class families without insurance can afford this....even for the parents, let alone their kids!

I know they have some expensive machinery to pay for, but I just can't see how these prices are justified in any way. Yes, I know prices are "set by the market", but I have never encountered any dentists that vary much in price, style of delivery, or services offered. I have also never encountered a profession so secretive about its prices. Receptionists never have a clue about what the price range would be to cap a tooth for example, it always "depends".

It would seem to me that doctors would likely have to take much more schooling, and they certainly have more advancements in their industry to keep up with, but in Canada at least, it is fairly common for a family doctor to make $150 to $200k per year. I reckon a dentist could easily make that in 3 months: $500/hour * 160 hrs/month * 3 months = $240,000. Yes, this is a simplistic calculation, ignoring the 4 dental hygienists working for him earning him $50/hr profit, possibly not 160 hrs/month billable (but equally possible billing equivalent of 260 hrs/month if he structures his staff right), must rent office and lease equipment, receptionist, etc etc....but you get the idea.

To me, something about the whole industry just doesn't seem right. It smells to me of collusion to some degree, but this is just pure speculation.

One other related thing I have noticed (anecdotally)....whenever you go to a dentist or doctor/clinic in Canada, there is always a big lineup, usually with at least a half hour wait, even with an appointment. The times I have visited a dental or medical office overseas (Thailand and Japan), there were either very short wait times, or I was literally the only person there....which makes me suspect the medical and dental associations here may be restricting the number of new applicants into schools, in order to control the supply of their services, and therefore the price.

Anyways, can anyone with some actual knowledge of the field could comment on my pure speculation?

ajtaylor• 16 years ago

The answer to your question about working families is that they simply wouldn't go because of the cost. The last time I had any dental work done (root canal + crown) I paid over $1k total, and that was WITH dental insurance. Teeth or rent - choose one.

ora6002• 16 years ago

It has to be determined by specific market conditions. I don't think anyone practicing dentistry in Israel earns anything even close to the sums you mention. As you said, there could be an artificial shortage in dentists. When my father lived in the US, he worked as a researcher, but didn't bother getting a dentist license because the process was too complicated and time consuming.

Dentists don't like to quote prices because they want you to choose them based on their skills and reputation. Letting you shop around would turn this into commodity market. They do know (at least in countries without strange insurance habits) how much each procedure should cost and how much each of their friends asks for. This is not exactly collusion, but can contribute to price similarity. The same way that you can't find a decent DBA in the bay area for less than 100k. People usually know how much their skills are worth.

Hope this helped.

alister• 16 years ago

This article further confirms the ridiculousness of asking friends and co-workers to recommend a dentist. I do trust friends and co-workers to recommend movies or restaurants because most people have seen hundreds of movies and eaten at hundreds of restaurants. Both most people have had only 1 or 2 dentists in their entire lives. They have no basis of comparison to say whether their dentist is any good.

You might as well choose randomly from a phone book. That's what I did when I moved to a new city. Actually I looked for dentists that were close to me, that spoke English natively (I live in a very cosmopolitan city), whose dental degrees were more than 5 years ago (gained experience) but less than 20 years (not outdated), and whose staff were pleasant and prompt on the phone (on the theory that the behavior of the staff will reflect the character of the boss).

Thus I picked my dentist without a recommendation and without meeting or speaking with him, but I think my method is less arbitrary than asking your friends and co-workers. (And yes, I do wish there was a better way.)

kmfrk• 16 years ago

I would be short of two teeth, if my mom hadn't had the resolve to get me a new dentist, just as the newly hired one began getting all sorts of weird ideas.

I was only there one time, and no harm was done, and no teeth were removed, but you can recognize many kids my from my city by them missing one or two teeth. I don't really know what to think of that, but it sounds like something straight out of a wicked story. I guess it is a wicked story.

Teeth are the most difficult part of your body to maintain, which makes it all the more awful considering how proportionally dependant you are on dentists compared to other experts you need regularly.

I was never afraid of dentists, because I was there to keep my teeth healthy (and as they always were, I didn't try nor fear a cavity and subsequent drill), but if I didn't have a dentist I loved dearly, I would probably shudder at the thought of them doing a sloppy job.

aplusbi• 16 years ago

I just recently got dental insurance again and now I'm kind of wondering how I should choose my dentist.

I was going to a dental school for treatment which meant that I was being treated by students under the supervision of dentists. They don't have a financial incentive to find cavities and everything is checked by two dentists.

It's possible that they have an academic incentive to find cavities (more practice for example) but at least two dentists have to agree with their assessment before they continue.

Unfortunately they don't accept insurance and my insurance company is kind of a pain when it comes to out-of-network dentists.

aaronbrethorst• 16 years ago

Now that I'm contracting and have to pay for dental care out of pocket, I've been thinking that the next time I go to a dentist, I'm going to tell them up front that I am only there to see them for cleaning and x-rays, and that I will be taking their results to another dentist for drilling and filling.

This interview just reaffirms my total lack of trust. It's like going to an auto mechanic. Setting aside notions of customer loyalty and karma, and what would happen if word ever got out, the auto mechanic maximizes their revenue by screwing over their customer.

"Well, of course they're trying to screw you. What do you think? That's what they do. They can make up anything. Nobody knows. 'By the way, you need a new Johnson rod in there.' 'Oh, a Johnson rod. Yeah, well, you better put one of those on.'"

http://www.seinfeldscripts.com/TheFusilliJerry.htm

noonespecial• 16 years ago

I've worked IT for a few dental offices. It's know as "drilling at shadows". (the dark spots on the xray are likely candidates for decay) Some dentists are more aggressive than others who take a "wait and see" approach. (You do go every 6 months right?)

Dentists will often drill and fill these dark spots "just to be sure". This is the first time I've ever really considered the financial angle and the perverse incentive that may also be at work.

The proliferation of digital xrays with instant networkable images creates a fascinating opportunity here. There's probably a startup in instant second opinions...

RK2• 16 years ago

My dentist used to be located in a dentist ghetto (i.e. a strip mall full of more than a dozen dentists' offices). At one point, when I had no dental insurance I was told I needed two fillings, come back in a couple weeks, etc. So instead of just walking to my car I went down the side walk and got price quotes from about 6 more dentists for the two specific fillings I needed. Prices varied greatly!

Dove2• 16 years ago

Misaligned incentives.

You shouldn't pay your programmers to fix bugs or lay down lines of code, but to produce working software. You shouldn't pay your doctor to treat you, but to make and keep you well. You shouldn't pay your mechanic to fix things, but to make your car run. And you shouldn't pay your dentist to fill cavities, but to keep your teeth healthy.

The DoD calls it performance based logistics. We build a system and promise to fix it whenever it breaks. If it's working X well for Y days of the year, we get paid $$$. Otherwise, we get paid $$ or even $.

It just makes so much sense. It weirds me out that maintainence is handled any other way. It's just begging for vendors to take advantage of consumers who don't know any better by selling things that are useless or even harmful.

Perceval• 16 years ago

Your scheme only works if the dentist can control for your genetics and veto your daily decisions to drink Coke, eat candy, and 'forget' to floss. But if your daily habits sabotage the efforts of a doctor who sees you only twice a year, the performance based logistics model doesn't really work.

Dove2• 16 years ago

The auto insurance industry seems to have figured out how to encourage drivers to behave safely. They say, in effect, "Based on what we know of your lifestyle, habits, and past rate of accidents, it will cost you $300/mo for us to assure your access to a functional car."

Don't see why dentistry should be any different. My auto insurance gives me about $8/mo off for having anti-lock brakes. My dentist could give me $X/yr off for brushing. (And he can tell...)

And of course, in general, I'm not trying to sabotoge his efforts. I want to be healthy as much as he wants to be paid. That is, after all, what I'm paying him for. If anything, it encourages him to encourage me to develop healthy habits.

thailandstartup• 16 years ago

How about using one dentist to recommend what work needs to be done, and checking the quality, and using another dentist to carry out the work?

melling• 16 years ago

I'd alternate going to my dentist and my girlfriend's dentist. My dentist always wanted to replace some of my fillings. My girlfriend's dentist never mentioned it. Once I even asked before the exam if my fillings needed to be replaced, telling her that another dentist said a few were bad. The final verdict: I was fine. I never went back to my dentist.

marze2• 16 years ago

A dentist in Michigan (Robert Nara) came up with a way for his patients to avoid all cavities. The state dental association had his license revoked or imprisoned or something. A threat to their summer homes and boats I guess.

I've tried his approach for a few years and so far no cavities. It comprises a hygiene regime designed to minimize the oral bacteria load by brushing immediate after eating and using salt water rinses.

wmeredith• 16 years ago

My wife is a dentist. I'll go ahead and call bullshit on this. The no-cavity-plan isn't some secret. It's no refined sugars in your diet and brushing & flossing religiously. (It's speculated that Neanderthal didn't get cavities. Ever. They had no refined sugar in their diet for the caries to feed on. They all did have horrible gingivitis and halitosis, though.)

It's the same way that the not-a-fatass plan isn't a secret, but most of this country (the US) is obese.

marze2• 16 years ago

Who said anything about a "secret"?

You can certainly google the dentist's name and read his account of his treatment by the dental association (this was back in the 70s if I remember right). I doubt he was making things up. I believe that when one of his patients came and tested with low oral bacterial count, the visit was free.

JangoSteve• 16 years ago

While I was in college, I admittedly went ~5 years without seeing a dentist.

When I graduated and got dental insurance, I immediately googled for "laser dentistry" in my area (having heard about it from my girlfriend). I chose the dentist with the highest ratings (well, one of the only dentists with any ratings at all).

Interesting fact: in 5 years, I apparently accumulated 5 cavities, none of them very serious. I got all 5 filled in under an hour, with no anesthetic whatsoever. Then, when I went for my checkup 6 months later, I had 2 new cavities. (Btw, if anyone is wondering, there is a low-power laser that reflects off your tooth enamel based on tooth density to determine which teeth need attention, and then there is a different high-power laser that actually gets rid of the decay).

Being my usual skeptic self, I started wondering if dentists didn't embellish reality a bit (or even create cavities while they're in there... ok, even I'm not that cynical, but I'd be lying if I said the thought didn't occur). Then again, my dietary and health habits probably did change considerably that first year after graduation.

In the end, I trust this particular dentist for a couple reasons.

1. He readily explains every step of every procedure he's doing, including how the tools work and why they work, even edge cases in which they wouldn't work. And he does so with enjoyment, like it's pleasant for him to have a patient interested in what he does. This appeals to the engineer in me.

2. He has said things to me like, "Well let's wait and see on that tooth. There's no reason we need to do anything to it just yet, it doesn't seem to be getting any worse." Also, when doing the laser fillings, he's asked, "Do you want anesthetic?" I responded, "do you think I need it?" And his answer: "Well, we can start without it, and then do it if things get too painful. No reason to numb you up and mess up your day if not necessary." Realizing that he'd get more money from me and my insurance if he used anesthetic, this alignment of interests was refreshing.

3. Given that every procedure I've had with him has been without anesthetic, I can say with certainty that he is extremely attentive to any pain I may have. He notices immediately if I wince at all, and makes adjustments accordingly, like turning down the power of the laser.

At the end of the day, I pay him for peace of mind, and he delivers.

shrikant• 16 years ago

Peripherally related, but too awesome to pass up on. This Is Going To Hurt Just A Little Bit, by Ogden Nash: http://wordysketches.blogspot.com/2010/07/this-is-going-to-h...

known• 16 years ago

DIY fillings http://www.ivoclarvivadent.com/en/all/products/restorative-m...

blahblahblah• 16 years ago

The conflict of interest problem could be significantly reduced by having a third party read the x-rays (i.e. make the interpretation of dental radiographs a radiology subspecialty or create a subspecialty within dentistry for doing this). This wouldn't have been very practical in the old days of film-based radiography, but with digital technology you could easily transmit all the images to a third party for reading. Having a dedicated specialist reading the x-rays would both address the conflict of interest problem (the specialist has no incentive to be biased; they'd get paid a flat fee to read the images and generate a report) and would very likely also improve the accuracy of cavity detection because the images would be read by someone who reads way more dental x-rays per day than any individual dentist ever would.

The 'Irrational' Way Humans Interact With Dentists

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