OT:Is That Biannual Dental Visit Necessary?

Investment Analysis Clubs Macro Economic Trends and Risks
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In a viewpoint published Monday in JAMA Internal Medicine, the researchers point out that many common—nearly unquestioned—practices in dentistry aren’t backed up by solid data. That includes the typical recommendation that everyone should get a dental check-up every six months. The researchers note that two large clinical trials failed to find a benefit of six-month check-ups compared with longer intervals that were up to two years.

A 2020 Cochrane review that assessed the two clinical trials concluded that “whether adults see their dentist for a check‐up every six months or at personalized intervals based on their dentist’s assessment of their risk of dental disease does not affect tooth decay, gum disease, or quality of life. Longer intervals (up to 24 months) between check‐ups may not negatively affect these outcomes.” The Cochrane reviewers reported that they were “confident” of little to no difference between six-month and risk-based check-ups and were “moderately confident” that going up to 24-month checkups would make little to no difference either.

The problem may date back to the 1970s and 1980s when fluoridated toothpaste became common, and the rate of cavities saw an “extraordinary decline.” That left dentists with a financial need to find new ways to keep their offices filled, even if teeth didn’t need to be.

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Well, that kind of depends. For some folk, it’s a totally inadequate interval to intervene in their departure from healthy homeostasis…for others, the reverse is true.

FWIW, there are more than enough folk who don’t bother with that timeline for a variety of reasons so, although there are no real RTCs to satify the naysayers (for the obvious reason of such studies would be unethical…maybe a tamer version of not treating syphilis to see what happens)…there’s plenty of empirical evidence that it’s a faulty recommendation.

Kind of a silly final conclusion because the lack of unequivocal data concerns the merits of the 6 monthly oral examination. The way that a longer time-line might reduce the number of “fillings” is that the number of RCTs (root canal treatments) and/or extractions is likely to increase…and then you’re really onto a nice little earner

I built my practice…and made a fair bit of money…from emergencies that didn’t need to be.

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Coincidentally, there was a piece on the news, in the last couple days, about cities being pressured to stop adding fluoride to city water supplies. I’m sure their next target would be toothpaste “adulterated” with fluoride. After all, the “Moms for Liberty” would tell us the truth, right? After all, they are “moms”, right?

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Absolutely!

Years ago I was at a dinner party with a young Naval officer who the service had sent to Loma Linda University to get training as an endodontist. He related a wonderful story to me about a classmate who’d done the arithmetic and calculated that he only had to do two root canals per month to make the lease payments on the top-of-line Mercedes. {{ LOL }}

Gave me a new perspective on the practice of dentistry.

intercst

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Well, I know what a bottom of the range Merc costs and how much root canals fetch too. I can tell you something…you were taken for a rube. Srsly.

Even if he happened to ply his trade out of the trunk of his motor, there’s still enough cost to materials used to eat into that lease payment.

Dude probably dined out on the story of how he told the one about lease payments on a pricey Benz for quite a while.

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Where I live a root canal in private practice is $1500 to $2,000 and here’s the current lease deals on the S-class Mercedes.

https://www.edmunds.com/mercedes-benz-s-class-lease-deals/

Of course, you need to know what the marginal cost of doing the last 2 root canals of the month (i.e, the cost after you’ve already covered rent, staff and overhead costs for the month, and the only additional costs are the expendables for the procedure: the files to clean out the canal, 2 or 3 syringes of lidocaine, the rubber dam required to keep the area around the open tooth clean, the bib to put around the patient’s neck, etc. If you’re purchasing those items in bulk, I’m guessing it’s less then $200 per procedure.) Volume matters.

I’ve had about 5 root canals done at the OHSU Dental School over the past 15 years, all by graduate endodontist students rather than general dentists. I always ask my student how many root canals per day it’s possible to do once you move on to private practice. There’s gold in high volume dentistry. {{ LOL }}

I should note that technology seems to have greatly improved the productivity of endodontic dentistry over the years. I spent about 6 hours in the chair for my first root canal 15 years ago and the student got brownie points for finding 4 roots in my back molar – apparently that’s unusual. I’m lucky I have a high tolerance for pain.

Root canal I had done on #15 ten months ago took about 90 minutes. Rather than spinning the tiny files with her fingertips while cleaning out the canal, my student had this nifty electric drill that held the files and made the operation go much faster. I wouldn’t be surprised if you can make the lease payment on a Mercedes with one root canal today if you have a practice in an upmarket area where you can charge higher prices.

It’s also worthwhile to note that with the state of American health care, a root canal is a luxury good – 75% of the population is getting an extraction instead.

intercst

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You’re moving the goalposts a bit here, no? The guy who bamboozled you with the 2 root canals story allegedly said only 2 root canals a month. Now you’ve graduated to the last two per month… when all costs of doing business have been covered by those banged out before, presumably. Sure, you’d certainly be able to make the lease payments on a Merc then…but what about all the other expenses of daily life over the month. Would the lease payments come before or after those? Yep…I can hear the guffaws around the officers mess right now. One born every minute.

Now about those 5 root canals…they sound like pretty good value in a cost/hour spent but a better way would be to have avoided the need for them in the first place. Yes, I know you can’t change what’s happened in the past but using the knowledge gained might change the course of your future dental needs. Were you given any insight into why so many root canals have been necessary? I was always tremendously grateful for the folk who volunteered to be patients when I was in training decades ago and willingly allowed me and my classmates to practice, practice, practice until we were able to demonstrate the minimal level of competence to be let loose on the unsuspecting public. Except for the ones who couldn’t demonstrate that level…even after all the practice. I thank you for your service.

In truth, it is totally possible to receive perfectly good care at a dental school. I have restorations in 7 of my 8 molars…all acquired initially before dental school was ever on my radar screen. All replaced at dental school ( before I graduated in 1975) and all but 1 still intact. No additions to the collection since. However, I was very selective in my choice of students…only the gold medal winners for my care.

My current dentist laughed at the similarity in our experiences there…and admitted that dh and I had stolen her thunder a bit as, before we joined the practice, she was the person who held the practice record for having the oldest fillings. My husband has me beat. Although he has had a handful of restorations replaced in the intervening years, he has a few that predate mine.

Avoiding the skim on dental care for, lo, almost half a century.

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No. The Loma Linda student (i.e., the Navy guy’s classmate) did a detailed calculation of the costs of running an endodontics practice. (this was back about 1988 or so) The Naval officer I was having the conversation with was a career Navy man. He was returning to the fleet after completing his endondontics training.

Yes. I’ve apparently been grinding my teeth for most of my life. Since I started going to the dental school, I’ve been wearing a night guard for probably 18 to 20 hours/day. I only take it out to eat or if I have to talk to somebody. I’m now a star pupil in night guard compliance. {{ LOL}}

intercst

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Aah…but read your post. You didn’t say after all expenses had been meticulously calculated. Sounds like the sailor was taken in also. Don’t get me wrong…your gullibility is understandable. When I chose dentistry as a career, I didn’t imagine that it’d be so darn hard to generate the income I sort of expected/hoped for. Working as an associate in someone else’s office was enough of an eye opener. Running my own show was that ×10.

In reality, I bet that Loma Linda student also had a similar rude awakening when they encountered the Real World.

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Yes, solo practitioners and small offices have it tough. The business-minded medical professionals who focus on volume are making bank.

Forty years ago I wondered why almost every medical office waiting room I was sitting in had a copy of “Medical Economics” magazine on the coffee table. Perusing it I learned about the wonders of “up coding your procedures” for billing purposes and the fantastic return you could get by adding one piece of medical equipment or another to your office inventory and selling it’s use to as many patients as possible. A few years later I learned that the medical journal in America with the largest circulation wasn’t the “New England Journal of Medicine” or the “Journal of the American Medical Association (JAMA)”, it was Medical Economics by a mile.

intercst

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I still have a couple of gold fillings from my teenage years - about 50 years ago.

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My husband has 2 gold inlays that a rugby playing pal did in dental school. He graduated 1971. By the time our dentist came to take her licensing exam, gold restorations had been removed from the graduation requirements. There aren’t likely to be many of you around …I’m assuming inlay (cast) as opposed to direct gold foil.

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Yep…I used to get Dental Economics delivered along with other free magazines (can probably boast the largest circulation among dentists for that reason) I restricted myself to just putting Readers Digest in the reception area. I actually purchased magazines of interest to me to supplement it.

Biggest patient complaint…I didn’t keep them waiting long enough for them to read what they wanted.

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I’ve had 3 dentists (well, 3 practices, 4 dentists, one for a very short time) in my life. I’ve never had a cavity in my adult teeth. Neither has my dad.

Dentist 1: Children’s dentist, general cleanings, I have a dim memory (mostly the weird taste of what he was ‘squeezing’ into my tooth) of the dentist filling a cavity at age 9 or 10 or nearly 11 (definitely before we moved homes). But I suspect (and my mom does too) that whatever the dentist did was unnecessary because that tooth fell out a few months after the procedure as the adult tooth under it pushed out.

Dentist 2: Once I was old enough, I went to my dad’s dentist that he had used since he had immigrated to the USA in the early 50’s. This guy was terrific. We used him until the late 90s when he semi-retired only took his “long-term” patients. Then he came down with Parkinson’s and stopped practicing altogether. My dad was still in touch with him periodically until his death a few years later. I even used him while I lived 5000+ miles away, every few months I had a business trip to the USA and would make a point to stop in the NY area for a day so I could go to my dentist (among other things).

Dentist 3: This was a local practice, a new young dentist working for an older one. The young dentist did my care for 2 years, but then moved away. Then the older dentist took over (1999 I think) and switched to using dental hygienists for almost everything. This was a good thing, because in my experience, dental hygienists (at least all the ones I’ve used in the ensuing 25 years) do a much better job cleaning than the dentist ever did. They take more time and also seem to have a steadier hand. This dentist is tricky though, he tries to “upsell” me whenever possible, and I’m ashamed to say that sometimes it works. For example, every 2 years they upsell me into a “deep cleaning”, that’s where they really dig deep under the gums and make a bloody mess. The insurance covers most of it, but I still have to pay a few hundred bucks. I don’t mind the deep cleaning because it seems to keep the gum line cleaner for longer, though for some reason my mouth develops huge amounts of plaque. Don’t know why, but the dental hygienist recommends that I come for a cleaning every 4 months. Another upsell that was successful was adding a veneer of some sort to two molars that he (the dentist) said were looking “worn down”. He painted something on the teeth and then cured it with some sort of uv light I think. I can still feel the front of those two teeth feel different than all my other teeth. Another upsell, just a month ago was some sort of oral cancer screening for $39 extra. I did it, but really shouldn’t have bothered. Another upsell that he tries every few years is to convince me to allow him to drill some of my molars and fill them, that’s because my molars have a few thin dark lines on their tops (the chewing surfaces). But I will never agree to that unless he can show me that there is a true cavity formed. That’s because those black lines have been there since at least 1999. I know it was 1999 because it was the new young dentist that told me about them, and told me not to worry about them unless they become true cavities. They also try to upsell on X-rays, but I only allow them every few years because not much is changing anymore and because my teeth were always a little crooked (I could have used a little orthodontic work as a kid, but we couldn’t afford such things at the time), so I don’t really care if stuff moves around a bit more at this point.

But I stay with this dentist because I am used to him, and I really like the dental hygienists that he has working for him. He has one right now that’s been with him for over 10 years and she does my cleanings every time except once (she was out on maternity leave) over those 10 years. She’s really good. I don’t know if hygienists are allowed to start their own practices, but if she did, I would follow her there. She does all my cleanings, and my deep cleanings every 2 years or so. The dentist comes in at the end for a minute or two to look around and pronounce “everything looks okay” and do his upsell routine. There have been all sorts of other upsells that I can remember over the years. Another one just from last month was this weird antibiotic rinse that they sold me and I used for 10 days. And they once sold me a water flosser many years ago. And they keep trying to sell me a fancy vibrating toothbrush for $149, but instead I got my last one from Amazon for $11.49. My hygienist asked me to bring my electric toothbrush in so she could inspect it and see if it’s any good, so I brought it last appointment and she looked it over and said it is a good one (I think I got it on sale at amazon for $15 a year or two ago) and had me brush with it and showed me some pointers how to brush better with it. I was brushing mostly side to side and she said to brush mostly up and down the teeth instead.

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Depending upon the state, dental hygienists can practice independently (can here in Colorado) They’re perfectly competent to do what they do…dental cleanings/sealant applications etc…however, very few practice outside of dental offices for the simple reason of finances.

Dental hygiene services are the loss leaders in a dental practice and it’s accepted that the drilling, filling, and billing is what goes a long way towards providing them with the compensation package that’s the reason they show up for work of a morning. The Dental Economics mag I mentioned earlier had all sorts of tips to make it possible for the hygiene department to pay its way but nothing that would induce a savvy consumer to pay the necessary amount for “just a cleaning”…deep or otherwise…or keep a hygienist in business on their own

It is a valuable flexibility when hygiene services are subsidized for, say community care purposes, so I’m in favour of practice flexibility for that reason alone.

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And from USC…

Nearly three-quarters of the United States population receives drinking water that contains fluoride, a practice that began in 1945 to help prevent tooth decay. But recent studies suggest that fluoride exposure can cause harm to a f@tus if consumed during pregnancy, a critical period for brain development…

The researchers found that a 0.68 milligram per liter increase in fluoride exposure was associated with nearly double the chance of a child showing neurobehavioral problems in a range considered close to or at a level to meet the criteria for clinical diagnosis…

These population-level findings add to existing evidence from animal studies showing that fluoride can harm neurodevelopment, as well as data from studies conducted in Canada, Mexico and other countries showing that prenatal exposure to fluoride is linked with a lower IQ in early childhood…

“This is the first U.S.-based study to examine this association. Our findings are noteworthy, given that the women in this study were exposed to pretty low levels of fluoride—levels that are typical of those living in fluoridated regions within North America,” said Ashley Malin, PhD, an assistant professor of epidemiology at the University of Florida’s College of Public Health and Health Professions and College of Medicine and lead author of the present study.

DB2