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Off-Label and Totally Legal: What the FDA Won’t Say About Fluoride Varnish & SDF

May 29, 2025 By Trish Walraven Leave a Comment

Fluoride Varnish and Silver Diamine Fluoride (SDF)

 

 

Let’s play a little game. Imagine your fluoride varnish brush could talk. You pick it up, ready to slather it across the facial and lingual surfaces of your patient’s teeth, and it whispers:

Psst… I’m only here for sensitivity.”

Excuse me? We both know that’s not the real reason you’re using it. You’re using it to prevent cavities. So why the double life?

Not-So-Secret Agents: Fluoride Varnish & SDF

If you work in dentistry, you know there are two magical fluids we love using to fight decay without breaking out the drill: fluoride varnish and silver diamine fluoride (SDF).

But here’s the kicker: neither is FDA-approved for the thing we all use them for – you know, the actual preventing or arresting of cavities. They’ve got their little badges that say, “I’m here to reduce sensitivity,” and that’s it. It’s like hiring a security guard to scare off pigeons and they stop a bank robbery instead. Not exactly their “official” job, but they’re killing it nonetheless.

So… Are We Doing Dentistry Wrong?

Not at all. This is what the grown-up version of medicine looks like: off-label use. That means we, as clinicians, are allowed to use products in ways that aren’t specifically written on the packaging, as long as there’s good science behind it and we’re not just winging it with snake oil and hope.

Fluoride varnish has been used off-label for decades to prevent caries. Every major dental organization (ADA, AAPD, CDC) backs it. It’s reimbursed by Medicaid for that purpose in many states. Even pediatricians – outside of a dental setting – are authorized to apply fluoride to children’s teeth under certain medical guidelines. But the label? Still just for hypersensitivity.

Silver diamine fluoride (SDF) – same deal. It got FDA clearance in 2014 for sensitivity. But its real superpower is stopping decay in its tracks. You paint it on a mushy lesion and – bam! – it freezes like Elsa just sang at it. Black, hard, ugly-but-healthy decay. Not glamorous, but incredibly effective, especially for kiddos, elders, and patients who can’t tolerate traditional treatment.

Why Not Just Change the Label?

Here’s the not-so-fun part: getting a new FDA indication is expensive. Like, “we could build a small dental school for this money” expensive. Most of the companies that make fluoride varnish and SDF are not Big Pharma. They’re more like Little-To-Medium-Sized Dental Supply. If their product is already being widely used and endorsed for the off-label thing? Why spend millions for a gold sticker that says “Approved”?

Also, if it ain’t broke (and no one’s getting sued), they’re not fixing it.

The Ethics and the Eyebrow Raises

Now, I’m not saying you shouldn’t know what’s on-label and what’s not. It matters. Patients deserve transparency, and we owe it to them to explain why their kid’s teeth are turning black (SDF, looking at you) or why we’re applying fluoride varnish after a cleaning even though they don’t have “sensitive teeth.”

The next time you brush on that fluoride varnish or dab a bit of SDF, give a little nod to its secret identity. Off-label? Definitely. Totally legal? You bet. Cavity-fighting? That’s the plot twist they didn’t print on the package.

TL;DR for Your Patients (and Curious Colleagues)

  • Fluoride varnish: FDA says it’s for sensitivity. We use it for cavities.
  • SDF: FDA says it’s for sensitivity. We use it to stop decay cold.
  • Both are off-label for caries, but not off-limits.
  • Science is on our side.
  • No one’s getting arrested. (Except maybe the cavities.)

What’s your take? Are we stretching the label, or just catching up to the science? Will this be one more talking point for those on the anti-fluoride side? Share your thoughts in the comments. 

References

  1. FDA 510(k) Summary for Advantage Arrest (SDF): FDA Clearance Database
  2. ADA Clinical Practice Guidelines for SDF: ADA.org
  3. ADA Topical Fluoride Guidelines: ADA.org
  4. CDC’s Take on Fluoride Varnish: CDC.gov
  5. AAPD Policy on Fluoride Therapy: AAPD.org

Filed Under: Dental Debates, Featured, Operative Dentistry, Preventive Care, Products Tagged With: American Dental Association, cavity prevention, dental controversy, dental hygiene, evidence-based dentistry, FDA approval, fluoride debate, fluoride safety, fluoride varnish, off-label use, preventive dentistry, SDF, silver diamine fluoride

A virtual care package from worried dental hygienists

April 2, 2020 By Trish Walraven 3 Comments

COVID-19 restrictions limit dental visits to all but emergency care, which means that millions of patients are overdue to have their teeth cleaned.

And because preventive services are not critical in the short term, all dental hygienists affected by the shut down are now out of work. However, the jobs will come back. What’s more concerning is the damage that may be happening in our patients’ mouths without a little extra intervention.

A few years back, do you remember the guidance that hygienists and dentists shared with you whenever we discovered that blue plastic bits were getting stuck under our patients’ gums? That was the dental community banding together here to get the word out, and we were able to convince manufacturers to stop adding plastic to toothpaste.

We’re coming together again in the same place, this time to pack a few personal items into your phone, tablet, computer, or whatever you’re looking at right now. This is the delivery we’re shipping to our patients, to take care of you with our thoughts and our hearts, and to share our best tips to make sure that you’re as healthy as possible at your next dental visit.

You want me to put my toothbrush where?

Care Package Item #1: Brushing your teeth with your other hand for the first minute, then switching hands.

This is all about about getting re-introduced to friction and tapping into novelty to help you learn something about yourself. When you pick up your toothbrush, you normally do so with your dominant hand. Instead (and this is THE KEY) you will grab your toothbrush with your other hand. If you’re a righty, then put your toothbrush in your left hand. Add toothpaste if you’d like and start brushing. Pay attention to how your gums feel when the bristles touch them. Most people don’t realize this, but they avoid touching their gums properly when they brush.

If it hurts to brush with your non-dominant hand, this is a sign that your toothbrush may be too hard, because soft brushes should feel pretty normal at this point. Keep brushing with your other hand, all around, then try to make the bristle contact feel the same when you place the toothbrush back in your dominant hand. It was surprising the first time I did this, because I realized I didn’t brush as well in areas that I thought I did. Even though I’m a hygienist, this helped me uncover weaknesses in my own brushing technique. Just watch out how you spit, because your other hand may now be in your trajectory field and end up all slobbery.

What’s your best flossing hack?

Care Package Item #2: Curved 3D flossers

As products go, this is a very specific one! There’s no substitute for using a string under your gumline, and if you have a tool that angles the string perfectly every time, you’re more likely to floss frequently and effectively. Make sure that your flosser is curved in 3D, not just flat:

With your 3D curved flosser, click the string between each place that your teeth make contact and floss deep under the gum tissue, once for each side, just like this:

I’ve demonstrated this on a front tooth for convenience, but the payoff of using these 3D flossers is when you get to really tight spaces in the back. My favorite brand is the Dentek Complete Clean Back Teeth, but there are others. Just make sure you purchase the curved flossers and not the flat ones.

Whoa, what should I do about blood or braces?

Care Package Item # 3: Soft Toothpicks

If you’re bleeding when you brush or floss, or can’t clean effectively with either of those items because of metalwork in your mouth, you’ve got to dig deeper. Remember, the stuff you’re trying to clean off of your teeth isn’t necessarily food; instead it grew there like a layer of pond scum, so you need to disrupt it as often as you clean your armpits.

Try gently poking deep into the areas that tend to bleed easily, like the gum pockets you’ve been told you have (that’s mine up there), or create some friction up in the gumline next to an orthodontic bracket or retainer wire. As long as you don’t feel any pain, you should be able to sweep away the germs that contribute to tooth loss with interdental cleaners like the Gum brand Soft Pick.

No toothpaste? Are you kidding?

Care Package Item #4: Brushing without toothpaste first

Hear me out – I am addicted to the feeling of mouth freshness. This is what the detergent industry has turned me into, a little mint whore. However, the foamy nature of toothpaste tends to obscure exactly what it is that I’m brushing, so periodically, I’ll spend the first 30 seconds of my brushing ritual without toothpaste. After that, it’s like an exciting reward, a delayed gratification of sorts. Hey, when you have to stay isolated from the rest of society for a while, the little joys start adding up.

Will overeating contribute to cavities?

Care Package Item #5: Swishing with water all day

A side effect of sheltering in place is boredom eating, which means excess carbohydrates fermenting in our mouths leading to a rapid increase in dental decay. To combat this, each time you eat, be sure to swish with a mouthful of water immediately afterwards. This will help you rinse away excess particles and acid. Remember – dentists are discouraged from filling cavities at the moment – they are more likely to be put in a position to pull an otherwise good tooth to get you out of immediate pain and danger of having a life-threatening dental abscess.

We’ve shared this article with you because we’re worried! Priorities are going to change in the coming months, and our careers are built on the foundation that patients should be able to keep their teeth for a lifetime with minimal professional care. Stay healthy, friends, and we look forward to seeing you back in the office as soon as possible.

Trish Walraven, RDH BS is a dental hygienist in the Dallas/Fort Worth area who is sad for so many of her colleagues that have lost their livelihoods. She would like to inspire her fellow hygienists and dentists to feel brave enough to share their concerns and best home care ideas so that we can begin the work of reconnection.

Filed Under: News, Preventive Care Tagged With: cavity prevention, dental hygiene, flossing, home care, toothbrushing

What is this $&!% on my toothbrush?

September 4, 2019 By Trish Walraven 2 Comments

This morning I threw my toothbrush into the toilet. That’s where it belongs, apparently, since I can’t seem to do the right thing to keep germs off of it.

See, a few years ago there was a big news story about the aerosols that are created with every toilet flush. I call this phenomenon “Fecal Fallout.” Let me explain: if a toothbrush is stored in the open air near a toilet, the debris from the bowl can be carried into the air and then sprinkled down onto anything within a six foot radius in a plume of doom. As a result, we may find ourselves brushing with the e.coli germs from feces if we’re not keeping our toothbrushes covered.

So if we’ve been keeping them covered, that’s not good either? Covering causes yet ANOTHER PROBLEM:

The growth that you see in this and the following image was accelerated by a few days, but this is really what happens! If we close in the moisture on our toothbrushes, we might as well invite a whole slimy rainforest to grow in there. It’s not just our toothbrushes that are being over-helicoptered. Mouthguards also tend to grow things on them if left unattended:

Nope. No way. I welcome the Demons Of TMJ Disturbance to visit me and make me dream about my teeth falling out all night. Sad that I’d rather grind myself down to gummy nubs than to have to clean that nightguard off and sleep in it again.

When someone tries to gross us out with a problem, there’s a reason behind it, because there must be an answer, a solution to the horrible thing that we want to prevent. What I like is that this solution happens to be quite economical and user-friendly.

No. Not that economical. You’re going back to the whole idea of “things that should be in the toilet.” But at least you’re thinking dry.

The Toothbrush Shield

As a dental hygienist, at times I’ve been merely satisfied with knowing my patients are using a toothbrush, but lately I’ve decided to acknowledge that they can be vectors for pathogens to invade our bodies if not managed properly. What’s excessive though, is how there are all these UV blue-light sanitizers on the market and other expensive gadgets you really don’t need to keep your toothbrush healthy. Along that path, I discovered the one thing that actually makes a lot of sense:

These covers both wick away moisture from your toothbrush and provide a physical barrier between your bristles and anything you don’t want them to touch, like your family’s other toothbrushes, bathroom cleaning chemicals, or stray hairs. I will never put my toothbrush in another plastic case now that I know about Toothbrush Shields.

This product is so obvious that I’m surprised I’m just now finding out about it. I want to get the word out why wicking sleeves should be as universal to our lives as something like plastic baggies. This particular wicking sleeve is designed for your toothbrush, and here are the reasons why I am endorsing the Toothbrush Shield:

  1. Affordable. A pack of 10 Toothbrush Shields retails around $4.00 at the time of this writing, and each one is effective for up to 7 days.
  2. Simple to use. Slip the cover on right after brushing, then your toothbrush can go anywhere! Your bathroom counter, luggage, purse, kids’ backpacks for quick sleepovers. No fumbling for a way to protect toothbrushes from questionable environments.
  3. Hospital-grade. The lightweight but quality material feels almost identical to the larger sleeves I’ve used to keep saliva and blood off of patient headrests in the dental practice.
  4. Made in the USA. Not only that, the company is woman-owned.

Part of that last bullet point is how I found out about this product. In the United States, 97% of dental hygienists are women. Other than kindergarten teachers (see the 2018 Labor Statistics here), the rest of the professions aren’t even close to having this extreme gender skew. So a short time ago I was at a conference exclusively for the dental hygiene profession – for all these women, essentially – where I was given a few samples of the Toothbrush Shield. Mind you, I was carrying a trade show bag heavy with familiar toothpastes, flossers, mouthwashes, and brushes from all the dental hygiene exhibitors. But this one product stood out, especially since I’d never seen anything like it before.

That’s where the “woman-owned” part comes in. While the person who invented the Toothbrush Shield is not a dental hygienist by profession, she has the insight to realize where her biggest advocates are poised, and most importantly, who they are, and what drives them.

Susan Klinsport

I’d like to introduce her to you. She is Susan Klinsport, an entrepreneur with a background ripe for solving the problem of germs and wet toothbrushes that she encountered in her personal life. Her experience working with engineering companies gained her the access to materials testing, scientific consultations, and manufacturing, and has resulted not only in the Toothbrush Shield, but she has also designed the larger version as a Mouthguard Shield.

I didn’t snag any of these Mouthguard Shields at the conference, so I asked for some images from Susan herself. I know, right? She’s like totally my best friend now. That’s because after the show was over, I was like “Hey,” and she was like “What” and I emailed her to ask about her story and everything. And she was really cool about it so here we are, on DentalBuzz, getting the word out about a simple, effective product that will protect yours and your patients’ toothbrushes by keeping them covered every day, and that takes the place of plastic cases and rolled up toilet paper when traveling.

So where can you get Toothbrush Shields? Probably just down the street! You’ll find them in stock at CVS, Walmart, and Rite-Aid. Or if they’re not on your local pharmacy shelves, you can purchase online from many retailers, including the IntellidentProducts.com website that will take you to the Walgreens retail page where a box is on sale for $2.28 currently. Good deal! Even if they’re privately labeled, they are still the same product, as you can see below:

Critical Cleanliness

Patients undergoing cancer therapy are especially vulnerable to secondary infections, so oncology clinics and individuals are able to purchase Toothbrush Shields in bulk here on the website at SideEffectsSupport.com, the world’s leading resource for minimizing oral effects of cancer treatment. The shields are also included as part of the Oral Cancer Rescue Kit as pioneered by Jill Meyer-Lippert, RDH of SideEffectsSupport.com and Jennifer Brown, RDH, BS of CARTI Cancer Center in Arkansas.

Aetna has gotten the message as well. The insurance company is currently including the Toothbrush Shields in their oral hygiene care packages as part of their Rush to Brush program, thanks to the efforts of Susan Klinsport and Dian Baker, PhD RN. This program is designed to decrease patients’ risks of acquiring infections during hospital stays.

Final words

There is also a great news story featuring Susan and the Toothbrush Shield that I wanted to share here:

I’m now using the Toothbrush Shields over my manual toothbrush as well as my electric ones. Why so many brushes? It’s because I’m currently going back and forth, comparing my previously shelved Philips Sonicare with the new Braun OralB that I received for free from the same conference, but that’s a story for a future article. All have been easier to remember to re-cover, and I’m looking forward to traveling with them now instead of closed-in plastic caps that I have to keep up with.

As for the toothbrush I threw in the toilet? It’s got a new job: scrubbing the dark grime out of the washing machine.

Trish Walraven RDH, BS has been curating DentalBuzz.com since 2008 as a casual place for dental professionals and their patients to explore dentistry in ways that make their lives better. This does not include firm toothbrushes, which is probably an equal factor for tossing that one that ended up in her laundry room.

Disclosure and copyright: Other than the samples, I did not receive any other form of compensation for this article. Feel free to share this information on your dental blogs, social media pages, or any habitats where patients and colleagues tend to dwell.

Resources and further reading:

https://www.allure.com/story/toothrbush-germs-bacteria

https://www.usatoday.com/story/news/nation-now/2017/04/06/youre-probably-brushing-your-teeth-fecal-matter/99785026/

https://www.onhealth.com/content/1/toothbrush_germs_facts

https://www.guardiandirect.com/resources/articles/shocking-facts-about-your-toothbrush

Filed Under: Featured, Products Tagged With: intellident, Toothbrush cover

The Prophy Jet Challenge

May 28, 2019 By Trish Walraven 4 Comments

Why you should improve proficiency at air polishing

No, we’re not daring you to eat your Prophy Jet. Read on.

What has changed little over the past 50 years and is the most performed yet overvalued service provided in dental practices? If you guessed rubber cup polishing, you’d be correct.

Overvalued? Sure—from a health perspective, polishing is more or less a cosmetic procedure. Then why do most patients still get their teeth polished with prophy cups and paste? It’s certainly not because it’s the most thorough way to remove plaque and stain; if it were, we wouldn’t have the need for adjunct cleaning methods. Often, the bulk of plaque and stain is removed with curettes, ultrasonic scalers and lavage, and the polishing paste is merely the finishing touch—the smoothing out that makes everything feel nice again after a major prophy jam session.

No, the reason that rubber cup polishing is the method used on probably 90% of patients in the United States is because it’s less technique-sensitive and equipment-sensitive. Not because it’s better. It’s also because of tradition. We find that prophy polishing is the standard of care because of what we experienced as patients in our childhood and also how we were taught to polish in school. You do it not because it’s right, but because it’s easier.

Rubber cup polishing is good enough … well, at least until it isn’t. Nowhere is the incompleteness of a prophy cup polish more evident than when trying to perform one on an orthodontic patient in full brackets and wires. Only then do you switch up your routine and reach for an adjunctive polishing system. Why? Because you’re relatively inexperienced using alternatives like air polishing on a regular basis, which translates into a messy melee for you and the patient, so the trade-off needs to seem “worth it.”

The only way to combat inexperience, though, is with experience, which you won’t get unless you start using your prophy jet on a regular basis. This means you’re being challenged to replace your prophy angle with the air polisher—yes, even on patients without a lot of stain or without orthodontia! But first, let’s dispel some of the biggest myths about air polishing that may have already caused you to dismiss the thought of making this change.

Myth #1: Air polishing is too messy.

It can be, but only during the learning phase or if you’re using poorer-quality equipment.

After air-polishing my patients almost exclusively for more than 10 years, I’ve found that the Dentsply Prophy Jet and Cavitron Jet Plus machines are unmatched for not only longevity and quality but also the ability to minimize overspray. Some lesser brands may not mix the water and powder into a slurry properly, so you end up with excessive powder all over the patient’s shoulders afterward. If you learn how to adjust the powder control, better angulation, correct working distances between the jet nozzle and the tooth, suction management and even patient positioning, over time you will realize that air polishing is no more of a cleanup disaster than prophy paste.

Myth #2: Patients hate the taste of baking soda.

What’s worse when you go to the beach on a windy day: tasting salt spray or biting into a sandy hot dog? I’d much rather taste the ocean. Why? Because it’s expected. You expect to taste salt water when you splash in the waves. The same can be true for your patients if you prepare them before you blast: Let them know exactly what to expect before you use the air polisher on their teeth for the first time. Explain why you’re using it instead of pumice, and you may be surprised at how many patients are agreeable about trying something new, especially if it benefits them. Try to use a powder that has flavoring as well, because this reduces patients’ perception that they’re being scrubbed down with household cleaning agents.

Myth #3: Air polishing doesn’t clean as well or feel as clean as prophy paste.

These should probably each be their own myths, but since they’re related we’ll keep them together. While prophy paste spins around in circles and does smooth the teeth nicely, guess what? Polishing paste also has a way of exaggerating the feeling that the mouth is dirty. Maybe your patient experiences this:

  • Prepolish:“My teeth feel normal—a little grimy, but nothing I can’t handle.”
  • Midpolish: “I have a mouth full of soul-crushing tiny rocks and sand that will kill me if I swallow.”
  • Postpolish: “Wow, smooth teeth! What a relief that’s over. Much better than grit!”

It’s interesting how perception can be shaped by going to extremes. This same contrast is what makes people think that black charcoal toothpaste makes their teeth whiter. There’s not much of a “midpolish” grit with air polishing if you’re using sodium bicarbonate, however, because it has low abrasiveness—especially compared with pumice. Also, because it can be directed into pits, fissures and interproximal spaces, air polishing cleans at least 30% more of the tooth surfaces than rubber cup polishing. Be honest: How well do you polish the occlusals of molars with a prophy angle? You may be surprised at how often you’ve been neglecting certain areas of your patients’ teeth after you’ve switched to air polishing for a while.

Myth #4: Air polishing will make sensitive teeth more sensitive.

The opposite is more likely, actually. Every once in a while, I’ve encountered a patient whose roots were too sensitive for the air polisher, but the vast majority of patients with sensitive teeth do better than expected. This is likely because bicarbonate crystals are capable of blocking the openings of the dentinal tubules. Just be cautious not to hover over individual root surfaces for very long and you should be fine.

As an alternative to the Prophy Jet, there are air polishers that utilize glycine powder or erythritol. These newer powders are not only friendly to sensitive root surfaces, but they are also gentle enough to use for subgingival biofilm management.

Myth #5: The aerosol created by air polishing creates excessive contamination.

That’s why preprocedural rinsing is recommended as a universal precaution to reduce airborne bacteria—not just for air polishing, but also for ultrasonic scaling and even for prophy cup polishing. While it is true that jet polishing creates more aerosol than prophy angles, there’s not a significant difference in bacterial overspray caused by jet polishers versus ultrasonic scalers.

Myth # 6: Air polishing is more expensive.

Economics is certainly a consideration when it comes to implementing any technology. The initial setup cost for a quality jet polishing system, including an adequate number of inserts to maintain proper sterilization, can be daunting. However, once the equipment is in place, there’s much less waste compared to disposable prophy angles and single-serve prophy paste cups. The polishing powder is the only recurring expense once the system is in place, and you’ll find that the cost of it can be significantly less than polishing paste. My favorite sodium bicarbonate powder is supplied in simple tear packets by Young Dental and has excellent consistency and flavor, in addition to being affordable.

Probably the best reason to implement air polishing, however, is because in the long run it’s going to be less expensive for the practice in terms of efficiency. A patient with moderate staining takes less time to polish with an air polisher than a patient with light staining and a prophy cup. This means less operator fatigue, especially if you begin mixing up your routine and becoming flexible as to when you polish during a prophy. It doesn’t need to be at the end to be thorough, or even to gain patient acceptance.

The challenge

Even if you often still reach for the rubber cup at the end of an appointment, you will find that having strong air-polishing skills will help you better tailor the care you provide to meet each patient’s needs, instead of feeling like you’re running each mouth through the exact same routine, all day, every day. I didn’t even go into depth about the newer types of air-polishing systems available out there for you to try! But that’s because the first step you need to make is the step away from your prophy angle. Do it for a week, especially if you already have a neglected air polisher somewhere in your office. Dust it off, be patient, and rise to the challenge that you’ve made to yourself to change this one thing for a bit. You will be a better clinician for it.

Trish Walraven RDH, BS is a dental hygienist who lives in the suburbs of Dallas/Fort Worth. She was very reluctant to move all of her patients to jet polishing when her co-hygienist first suggested the change, but is very grateful to her and to all the patients over the years whose encouragement and feedback helped her realize that there was no going back to prophy cup polishes.

Ready to roll? Here’s a video tutorial from Dentsply to get you started:

Filed Under: Featured, Hardware, Instruments, Operative Dentistry Tagged With: air polishing, baking soda, dental cleanings, dental hygiene efficiency, Dentsply, Prophy jet, sodium bicarbonate

Why dental insurance makes good people do bad things

January 10, 2018 By Trish Walraven 32 Comments

When I was a kid, my dad would tell me on the way to the dentist to be prepared to pay out of my own pocket for any cavities I had. $38 per filling was an insane amount of money for an eight year old with a 75 cent allowance per week and 7-Eleven candy habit. I hedged my bets that his threats were empty, that I’d get my dental care and never have to pay up.

And it worked. Since I didn’t have a proper income, my parents went ahead and took care of the bills for me, got me to the dentist, fixed those cavities right up. Instead of making me pay in cash, however, I paid up in guilt, for not taking care of my teeth like I should have.

I carried that guilt for years, right into college and ultimately into dental hygiene school, when I learned something interesting about the type of fillings that were in my teeth: if I’d had sealants as a child, there would have existed the possibility for me to grow up cavity-free. But sealants weren’t widely available to dentists until the mid-1980’s, too late to save me from the drill.

That’s the thing, though. Dental practice is not malpractice if it’s within the current standards of care, so my dentist growing up was in no way neglectful of my dental health. It’s just the way things were then. I have a bunch of pits and fissures in my back teeth full of silver instead of smooth white sealants, like my kids do – all those deep grooves they inherited from me were sealed just as soon as their permanent teeth came in.

Dentists and hygienists have a belief ingrained in us throughout our education: The best dentistry is NO dentistry, because natural healthy teeth will almost always be better than man-made teeth. We are driven to help you keep your teeth in their most natural state as possible, for your entire life. We can’t do this, though, unless you visit us for preventive care. Our experience and training lets us see the earliest signs of things that aren’t quite right in your mouth, so that we can help you take the necessary steps to correct them way before they become disfiguring, painful, or expensive.

This might be a good time then to start talking about dental insurance. Before we do that, though, let’s explore more generally. What is insurance? It’s money you pay to someone else to take care of things if the unexpected happens.

If you’re fortunate enough to never have a house fire, or die, or crash your car, there’s nothing that your insurance policies need to cover, so you’ll never get a reimbursement check. Medical insurance used to be a reimbursement system, too, until insurance companies had to come up with clever ways not to cover people’s health problems so that the insurers wouldn’t run out of money. Hospitals and doctors also became clever with their billing, and this back and forth game of “how can we make the money flow in our direction” has resulted in our current health care situation.

This cleverness has also invaded dentistry. Here are three truths that exist right now:

1. A lot of people have crappy dental plans

2. They go to dentists they don’t trust and

3. Get treatment they don’t need.

Do you want to help me change these three truths? You can, you know. We’ve done it before, you and I. You helped me get the word out that plastic in toothpaste was a bad idea, and we got that banned in the United States shortly afterwards. This is so much bigger: helping each American keep their teeth for life, at a cost they can afford.

To do this, we’re going to have to get everyone working together, but differently. You can’t change the system by just saying it needs to be changed and then doing nothing from your place within it. There’s also no ability to change if you don’t understand how to make a difference with your own actions. Right now, inadequate dental insurance is the standard of care, sort of like silver fillings were in the 70’s. Are you ready to help me move dentistry another big step forward?

Look at yourself in the mirror.

This is where it starts. With you. What do your teeth mean to you? Are their appearance important, or is it good enough that they don’t hurt and you can chew with them? Take a hard look at your teeth, and answer these two questions honestly to yourself.

Believe it or not, dentists spend a lot of time trying to guess people’s values. If you don’t know how you feel about your own teeth, then how does your dentist decide what’s right for you?

Natural teeth are going to be everyone’s first and best option. You get the first two sets of teeth for free – they’re given to you, as part of your body. If you’re fortunate enough to have parents who were able to take you for early dental care, who reminded you to brush your teeth regularly, who did their best to manage your habits and your diet, then you are less likely to need a third set of teeth. Without getting into details, let’s agree that anything dentist-made in your mouth which takes the place of natural teeth is part of the “third set.”

That dentist-made stuff, though, is the set of teeth that ends up costing a lot of money. Fixing teeth is how dentists stay in business, after all. But it’s also where insurance breaks down, on that third set of teeth. Even the best plans only cover, at most, the dollar equivalent of about 2 dentist-made teeth per year. If you have 28 teeth, that means you’ll have to use up all your benefits, every year for 14 years to get your third set of teeth paid for. If your insurance only pays for 2 teeth per year, but you have 10 teeth that are in trouble, what do you do, only treat a few and let the others all rot while you’re waiting on your insurance checks?

Something else you need to admit to yourself is to make the realization that you’re not immune to the lure of the bargain. Too often, that’s all dental insurance is. It’s sold to you as a bargain, or something that you have to have to get in the game, when the reality is that it’s only a game. Take this example:

Yep, that insurance made a $755 dent, which is big. But at what cost? Were the fillings and crowns built to last, or will they need to be replaced in less than five years since you felt you had no other dentist who would take your insurance and the one that you did go to didn’t seem to do that great of a job?

Let’s back up now and talk about your first two sets of teeth. You get the baby set as a toddler, the other set as you grow up. Both of those sets of teeth don’t cost anything; they just sort of show up one day, ready to get to work. And they need a dentist to check in with them every so often, to say hey, howya doin? Everything all right in there?

That’s what most people think of as a check up, and if you’ve had good luck with your teeth so far, it’s safe to say that having at least one dental visit per year will assure that someone’s keeping a professional watch on them.

Checkups are cheap.

Can you afford $50 per year? That’s the current average cost for a routine dental checkup in the US, across all dentists – city dentists, rural dentists, group dentists, solo dentists.

If dental checkups are not crazy expensive, then why isn’t this common knowledge?

Have you assumed that basic checkups cost more than $50? If you have, you’re like most people. It’s probably why you’ve been worried about the cost of going to the dentist, why you’ve been worried about not having insurance, why you make sure that the dentist you choose takes your plan, why you visit low cost clinics. You haven’t known the cost of the alternative.

This knowledge is your power. You can go to any dentist, and $50 is the average price for a periodic examination – this what they will charge to take a look at your mouth during a routine visit. It’s a little more for your first time, say $75-$100. A series of four bitewing xrays? Usually less than $60. Certainly not free, but all together not as much as you may have imagined.

So let’s bring insurance into our discussion once again. Remember, insurance, for everything except your body, pays nothing until there’s an unexpected event. A dental checkup is not unexpected – it’s prevention! And if you’ve ever worked with dental insurance, you know this: Almost every dental insurance policy completely covers the cost of a checkup. But they don’t do so universally. With many of those checkups, your insurance will only cover the cost if you visit certain dentists.

Dental insurance pretends to pay for your teeth.

If it really paid for them, like insurance is designed to do, it would cover the unexpected problems, especially in emergency situations. Instead, dental insurance gives you just enough coverage to make you feel like it’s a value, and scares you into thinking you can’t go to the dentist without it. Most plans offer a fixed dollar amount, around $1000, to use per year, and that’s it. If repairing your teeth costs significantly more than your maximum, it’s not protecting you. Dental insurance shouldn’t even be called insurance, because it works more like a dollar-off coupon. $1000 off of a $6000 treatment plan is at best only a 17% discount. Call yourself a sucker if you tolerated care at your “in network dentist” so that you could get less than 20% off the cost of going to a dentist of your choosing.

Dental insurance changes how dentists care for you.

We have been conditioned to believe that a procedure must be the right thing to do because “insurance will pay for it.” There is a sweet spot, right in the middle of insurance plans that covers so much more of a percentage of the total cost than either end. People with healthy teeth get basically a 20% discount for the cost of their care after taking premiums into consideration. It’s also 20% off of the cost of really expensive needs like crowns and dentures. But look how the dental benefit skews within the middle tier of dental needs:

Whoa! It jumps up to 60%. This can go one of two ways:

1. There are a few things you really need to have done, and insurance will help out a lot!

2. Your insurance will get billed for stuff you don’t need because you won’t have to pay for it yourself.

This doesn’t bother me all that much for preventive care because it’s not permanent and mostly reversible. But when dental offices intentionally “massage the insurance” to abuse this 60% sweet spot, a dentist might take a drill to a tooth that didn’t really need it, and guess what? You’re damaged. You’ve actually been broken by someone you trusted to take care of you. They took out a piece of your tooth, forever, and you can never grow it back.

Destroying healthy tooth enamel for profit makes me angry.

I’ve seen this dressed up at dental practices to make it sound like they have patient’s interests in mind. It might be called “their philosophy of care” but really, you’d be surprised how many people exist whose paychecks are dependent upon exploiting insurance codes to get the most money for their practices. “Maximizing fee schedules” is their philosophy of care. And you are a pawn to them. This is the essence of why dental insurance makes good people do bad things.

 

Exploiting Insurance Codes for Maximum Dollars.

Let’s blow this up a little and list some of the ways that insurance is abused. You may want to be on alert when you see these on your treatment plan or billing statement:

Core Buildups. This article from the American Association of Dental Consultants states, “In the last twenty years there have been a reported increase in the number of core buildups submitted to dental benefit plans out of proportion to the increase in crown submissions….Also growing are the numbers of dentists who admit, with no compunction, that they place core buildups under every crown they seat regardless of need. The financial ramifications from this trend are significant since a core buildup can add twenty to thirty percent to the final cost of a crown.”

Periodontal scaling and root planing. Often called a “deep cleaning,” gum disease treatment is the primary weapon against tooth loss, but it is a time-intensive procedure. If an office charges out periodontal therapy but you weren’t even numbed, or it took less than an hour to have treatment in all four sections of your mouth, that’s a reason for your eyebrows to go up. Also, be cautious of any dental office where your routine cleaning appointments seem super-speedy, according to this article, or if you’ve always been healthy like this person.

The need for many fillings suddenly. You’ve been off and on with regular dental care, and have had few fillings in your life. Then you visit a new dentist and are told that you have a lot of cavities. According to this article from the New York Times, some doctors may wait longer than others and “watch” small cavities, but if you feel suspicious, you should definitely seek a second opinion before the drilling starts. One pediatric dentist’s editorial on the ADA website goes so far as to call this “creative diagnosis.”

Replacement of silver fillings. Sure, they don’t last forever. But silver fillings do typically last longer than tooth-colored fillings, and if there is no pain or an obvious hole or cavity in a tooth with one, most dentists won’t try to scare you into changing them out, especially not all at once. The National Council Against Health Fraud issued this statement defending amalgams. I personally have six silver fillings that are around 40 years old, and they all still feel better than the two that were replaced.

Procedure Upselling. Any time a dental practice uses intimidation to get you to agree to something, that’s wrong, regardless of whether or not the treatment is appropriate or covered by insurance. Don’t ever feel pressured, especially if you’re in a vulnerable position, to agree to whitening, bite guards, cancer screenings, or even orthodontic care. A reputable dentist will let you take your time to make decisions about your mouth.

Suspicious dates or billing. Look over these examples of fraudulent and abusive practices; these may be signs that a practice is illegally obtaining insurance benefits on your behalf.

Preventive care is not immune.

With preventive care, dentistry as a whole tends to over-treat because, after all, “insurance will pay for it.” Big Deal, We took better care of them than they needed, who cares, we all win, blah blah. When someone feels entitled to an insurance benefit because, by George, it needs to be worth SOMETHING for all those dollars, that’s when you’ll agree when your hygienist says “see you in six months.” I guarantee that every hygienist has patients for whom getting their teeth cleaned every six months is complete overkill. Some people simply have nothing on their teeth to clean off. We spend most of your appointment scraping at stuff that’s not even there, despite our best efforts to find it. I’ve done it, lots of times, and it’s frustrating because the patient expects a cleaning every six months and we truly want everyone to feel like we’re helping them stay healthy.

That’s what I mean. There is no motivation to correct the situation. The insurance pays for cleanings every six months, so no one will challenge the perception that having your teeth cleaned twice a year is not necessary. Money is wasted, but to the patient, they “miss out on their free cleaning.”

This gets super abused in dental practices that are dependent upon patients who have insurance to stay in business. The more dependent, the more likely the abuse. That’s not to say that most dental practices are doing their best to stay within the standard of care, while carefully checking everyone’s insurance plans. Cleanings twice per year? Checkups twice per year? X-rays once per year? Everyone is treated the same. The six month visit is a safety net, and both patients and clinicians accept it because of what insurance covers, not because treatment is necessary.

On the other hand, insurance dependence can also can cause a dental practice to neglect your needs. The dentist is less likely to tell a patient to have X-rays every six months if their insurance doesn’t cover it, even if the person is suffering from severe dry mouth that is resulting in a lot of new problems that can be diagnosed with the help of more frequent imaging. If you need your teeth cleaned more often than what your insurance will pay for, an office may simply let that recommendation slide past. You are much less likely to get personalized care when you allow insurance coverage to dictate what gets done, and when. You’ve allowed yourself to be seen as “the person with insurance who is not going to pay for anything that it won’t cover.” Even if you don’t feel this way. It’s like a trap. Not just to patients, but to clinicians as well.

The Five Traps of Dental Insurance.

Trap #1: DMOs that bill for treatment above and beyond their negotiated rates. Dental Maintenance Organizations are lowest tier of dental insurance. Dentists on these plans get capitations, which are small monthly payments for being on the provider list. To be profitable they need to bill out as much treatment as they can. Patients have come for second opinions (note: always get a second opinion if you’re unsure!) after visiting a DMO practice enough times for me to see a consistent trend of overcharging for excessive care; not just hundreds, but for thousands of dollars of treatment, out of pocket. If you have insurance that only lets you go to one or two clinics that have many doctors who cycle in and out of the offices, you probably have a DMO plan.

Trap #2: Missing Tooth Clauses. Sometimes having a tooth removed is the least expensive way to get out of pain. If you’ve ever lost a tooth, unless you had your existing insurance in place, the replacement of that tooth in the future won’t get covered. So much for getting your teeth back to working order. To the insurance company, a missing tooth is considered a pre-existing condition, so it’s your responsibility, not theirs.

Trap #3: Waiting Periods. Now you have insurance, but you’ll have to wait six months to a year to pay into the system before it might give you that money back, plus a little more? Individual dental insurance plans are notorious for waiting periods.

Trap #4: Major treatment. We’ve already established that less expensive the dental service, the more likely your insurance is to cover it. What about the expensive stuff? If it costs more than $300 per tooth or section, then your insurance will most likely only cover half of that. Ever. End of story. Need dentures? A crown? A wisdom tooth removed? You’ll have to pay at least half the bill, if not more, even if you followed the rules and went to the dentist on your plan.

Trap #5: Discount dental plans. There’s one type of discount plan you should run, run, run away from – those are the referral services. They’re not really even discount plans, if the truth must be told. You pay a fee to a third party. That third party gets to keep some of your money, and in return you receive a list of dentists who will “accept” a reduced cost for a few treatments. In the meantime, the third party often encourages the dentists on their list to compensate for their reduced fees by billing for services not bound by the discount plan. I would be cautious of any dentist who uses this method to find new patients.

There would be no game of chess if the pawns refused to play.

So how do we encourage good people to stop doing bad things because of dental insurance? There’s only one way: Stop the flow of money! Have a crappy dental plan? Don’t allow your money to fund it. And if insurance abusers have no patients, they’ll eventually stop the bad behaviors.

You’d be surprised how many dentists out there would be thrilled if even half their patients decided to do everything they could to save money. The reason most dentists got into the profession? They love knowing that they’re helping people. And if the main reason you go to the dentist is to save money in the long run, they will be pleased that you chose them to partner with you to work towards that goal.

You can afford to go to the best dentists in town.

What if you could always visit the absolute best dentists, the ones that you thought only the most wealthy people visit, and you would get better and cheaper care there?

You can, and you should. The best dentist is the best, not because they cost the most, but most of the time, because they cost what you decide they cost. The best dentists have built something very important in the community that brings many people to see them.

This is where the biggest, most powerful word in dentistry comes in.

Trust.

That word goes both ways. Too many dentists don’t trust their patients to make good choices about their teeth, so they often only present one option. This is it, period. This is what your mouth needs, like it or don’t, but this is what you need, and what it costs, and this is just what we do around here and how we do it.

Instead, a good dentist will listen to the people they serve carefully, and trusts that the patient will share enough about their concerns to be able to formulate several options, not just a single option, especially for more complex care. If the financial burden even to get someone out of pain is too much, the “best dentist” is still the best value for an honest opinion. Think of them as the gatekeeper, the one who knows which dentists in your neighborhood to steer clear of, the ones who do not seem to value trust.

But they don’t take my insurance.

Seriously, you came through all of this with me, and you’re still stuck on insurance? Do you want dentists to treat your insurance, or do you want them to treat you? A good dentist’s goal is to put you in charge of your own care, and follow your values as much as possible, which is how you’ll truly end up saving money.

Should I keep using my insurance?

Sure! If you’re lucky enough to have even minimal dental insurance and you trust the practice where you’re already a patient, there’s no compelling reason to make a change just because you’re not happy with your plan. If not, it may be time to find a real dental home, one that will do honest work for honest pay, and not play games with your health, your money, and your insurance company’s money.

What is the best dental insurance?

You are fortunate if your dental insurance policy has just one or more of the following features:

  1. You pay nothing extra per month for your dental plan.
  2.  You can go to any dentist you want.
  3.  You have no maximum dollar limit.
  4.  Major services are paid for at 80%.

If none of these apply, then your insurance probably costs you more than you receive from it. My suggestion would be to opt out of your dental plan and let yourself get paid a little more per month instead. Then if you simply must be on a plan, many dentists offer their own form of in-house insurance, where you pre-pay for your preventive care each year and in return you get a percentage discount for any other services you’ll need. It’s sort of like a twice-yearly gym membership, with reduced pricing for personal training sessions.

I still wish someone else would pay for my teeth.

Me too! Wouldn’t that be great? But there came a point in my life where my parent’s money stopped being my dental insurance. I had to accept that my teeth were my responsibility, and that I would have to find a way to help them stay as natural as possible. Even with a career working daily in a dental practice, I’ve always had to pay out of pocket for the level of dental care that I value. One cleaning, checkup, and set of X-rays per year costs about $150 in my area, which isn’t worth jumping through insurance hoops for.

In the meantime, if you don’t have someone else paying for your teeth (like a rich relative or a great insurance plan), go to the best dentist you can find, explain that you’re done with “what insurance will cover” and ask them to treat you like a human being instead. You might just be surprised at the quality of care you receive for the cost.

And none of us, on either side of the equation, will miss the dental insurance game, not one bit.

 

 

Trish Walraven, RDH BS is a dental hygienist in the Dallas/Fort Worth area who is proud of the quality dental work that was placed in her mouth as a child and is still keeping her teeth strong today. She champions those who will not accept anything less than good dentistry, and hopes that her explanation of dental insurance and its flaws inspires you to share this article’s message with your friends, family, patients and colleagues.

 

References and further reading:

How not to get ripped off at the dentist:  https://askthedentist.com/
Dental insurance: A systematic review: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4278106/
USA 2016 Dental Expenditures: http://www.ada.org
Dental Insurance “Scam” or Not: https://collegetimes.co/dental-insurance/
A screenshot from a referral/payment service:  Cost Comparison screenshot
Sealant review of the literature: http://citeseerx.ist.psu.edu/
How to Know when Tooth Fillings are Unnecessary: https://www.wikihow.com/Tooth-Fillings
The Truth About Dental Insurance: https://www.blodgettdentalcare.com/
Dental Insurance: Facts and Reality Checks: http://www.dentalleaders.com/facts/
Dr. James Pedersen, DDS. Dental Dilemma: My Experiences in the Dental HMO Field
Misrepresentations to Consumers: A Dark Side to Dentistry. http://www.dentistrytoday.com/news/

Thank you also to Concerned Dentists of Texas – https://concerneddentistsoftexas.org – for their help in mobilizing dentists to get this story out to their patients and the public.

Filed Under: Dental Debates, Featured, Money, Practice Management, Preventive Care Tagged With: affording a good dentist, best dental insurance, dental insurance, dental overtreatment, good dental practice, How insurance works

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